Healthcare Provider Details

I. General information

NPI: 1013074608
Provider Name (Legal Business Name): JENNIFER GORDON ELZEY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EAGLE LN
ADAIRSVILLE GA
30103-2531
US

IV. Provider business mailing address

101 EAGLE LN
ADAIRSVILLE GA
30103-2531
US

V. Phone/Fax

Practice location:
  • Phone: 770-773-9811
  • Fax: 770-773-3699
Mailing address:
  • Phone: 770-773-9811
  • Fax: 770-773-3699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12033
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: