Healthcare Provider Details

I. General information

NPI: 1548960438
Provider Name (Legal Business Name): AMANI KASUMI GORDON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 DRESDEN DR NE
BROOKHAVEN GA
30319-3581
US

IV. Provider business mailing address

1441 DRESDEN DR NE
BROOKHAVEN GA
30319-3581
US

V. Phone/Fax

Practice location:
  • Phone: 404-254-1128
  • Fax:
Mailing address:
  • Phone: 212-305-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124296
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: