Healthcare Provider Details

I. General information

NPI: 1548616238
Provider Name (Legal Business Name): GRANT CHRISTIAN BURGDORF D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 MT VERNON RD, SUITE 200
ATLANTA GA
30338
US

IV. Provider business mailing address

1505 MT VERNON RD, SUITE 200
ATLANTA GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 770-396-7321
  • Fax: 770-396-4936
Mailing address:
  • Phone: 559-361-4154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number059402
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015915
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN015915
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030235
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: