Provider Demographics
NPI:1154574721
Name:THOMAS, JERRY JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JASON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4724 EAGLES RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3537
Mailing Address - Country:US
Mailing Address - Phone:770-484-7645
Mailing Address - Fax:770-484-7745
Practice Address - Street 1:8200 MALL PKWY
Practice Address - Street 2:STE 200
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6983
Practice Address - Country:US
Practice Address - Phone:770-484-7645
Practice Address - Fax:770-484-7745
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126421223X0400X
MI29010180521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics