Healthcare Provider Details

I. General information

NPI: 1043899453
Provider Name (Legal Business Name): ANTHONY JUSTIN BURGOIS MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2021
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1365 CLIFTON RD NE STE 2300
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4555
  • Fax: 404-778-5879
Mailing address:
  • Phone: 404-778-4555
  • Fax: 404-778-5879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123020
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number17683
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number17683
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: