Healthcare Provider Details

I. General information

NPI: 1881729820
Provider Name (Legal Business Name): JACQUES LENOEL GORDON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 PRINCETON LAKES WAY SW STE 408
ATLANTA GA
30331-5589
US

IV. Provider business mailing address

3885 PRINCETON LAKES WAY SW STE 408
ATLANTA GA
30331-5589
US

V. Phone/Fax

Practice location:
  • Phone: 404-629-6610
  • Fax: 404-629-6630
Mailing address:
  • Phone: 404-629-6610
  • Fax: 404-629-6630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013463
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: