Healthcare Provider Details

I. General information

NPI: 1376522722
Provider Name (Legal Business Name): JUSTIN WILLIAM BORDLEMAY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10055 FORD AVE STE 3C
RICHMOND HILL GA
31324-3972
US

IV. Provider business mailing address

PO BOX 1885
RICHMOND HILL GA
31324-1885
US

V. Phone/Fax

Practice location:
  • Phone: 912-445-5311
  • Fax: 912-445-0738
Mailing address:
  • Phone: 706-627-5358
  • Fax: 912-445-0738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013841
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: