Provider Demographics
NPI:1063599413
Name:LESTER, JACK (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LESTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 FLAT SHOALS AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1915
Mailing Address - Country:US
Mailing Address - Phone:404-688-2223
Mailing Address - Fax:404-688-6602
Practice Address - Street 1:440 FLAT SHOALS AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1915
Practice Address - Country:US
Practice Address - Phone:404-688-2223
Practice Address - Fax:404-688-6602
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000438666AMedicaid