Provider Demographics
NPI:1912349994
Name:DESAI, JIGAR ASHOK
Entity Type:Individual
Prefix:
First Name:JIGAR ASHOK
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 PINE COVE DR
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1401
Mailing Address - Country:US
Mailing Address - Phone:770-401-4190
Mailing Address - Fax:
Practice Address - Street 1:919 PINE COVE DR
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1401
Practice Address - Country:US
Practice Address - Phone:770-401-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2018-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15473122300000X
GADN0157421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist