Provider Demographics
NPI:1124239512
Name:GOLSEN, JILL M (DMD)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:M
Last Name:GOLSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14905 E BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-3161
Mailing Address - Country:US
Mailing Address - Phone:770-667-0669
Mailing Address - Fax:
Practice Address - Street 1:3400A OLD MILTON PARKWAY
Practice Address - Street 2:SUITE 430
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005
Practice Address - Country:US
Practice Address - Phone:770-667-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist