Provider Demographics
NPI:1043802655
Name:YUAN, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:YUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 TERON TRCE STE 600
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1664
Mailing Address - Country:US
Mailing Address - Phone:770-614-8823
Mailing Address - Fax:
Practice Address - Street 1:2098 TERON TRCE STE 600
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1664
Practice Address - Country:US
Practice Address - Phone:770-614-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1233291223P0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program