Healthcare Provider Details

I. General information

NPI: 1417513730
Provider Name (Legal Business Name): JORDAN ALEXANDER REZNIK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 PERIMETER CENTER PKWY NE STE C-30
ATLANTA GA
30346-1402
US

IV. Provider business mailing address

191 STEWART DR
ATLANTA GA
30342-1907
US

V. Phone/Fax

Practice location:
  • Phone: 404-625-3009
  • Fax:
Mailing address:
  • Phone: 404-406-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD015858
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDN015858
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: