MEDICARE: DR. JACQUES LENOEL GORDON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN013463	GA

General Provider Information

NPI Number	:	1881729820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUES LENOEL GORDON DMD

Provider Business Mailing Address
First Line	:	3885 PRINCETON LAKES WAY SW
Second Line	:	STE 408
City	:	ATLANTA
State	:	GA
Zip	:	30331-5589
Country	:	US
Telephone Number	:	404-629-6610
Fax Number	:	404-629-6630

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY SW
Second Line	:	STE 408
City	:	ATLANTA
State	:	GA
Zip	:	30331-5589
Country	:	US
Telephone Number	:	404-629-6610
Fax Number	:	404-629-6630

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	04/29/2010

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