Healthcare Provider Details

I. General information

NPI: 1780888693
Provider Name (Legal Business Name): TERESA DANIELLE JORDAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2646 GRESHAM RD SE
ATLANTA GA
30316-4148
US

IV. Provider business mailing address

150 MILANO DR SW
ATLANTA GA
30331-8381
US

V. Phone/Fax

Practice location:
  • Phone: 404-212-9060
  • Fax: 404-212-9020
Mailing address:
  • Phone: 770-449-0836
  • Fax: 770-441-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: