Healthcare Provider Details

I. General information

NPI: 1679927750
Provider Name (Legal Business Name): JORDAN NICOLE BLANKENSHIP-SNIKER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MARKET PL STE 200
ROSWELL GA
30075-3943
US

IV. Provider business mailing address

380 MARKET PL STE 200
ROSWELL GA
30075-3943
US

V. Phone/Fax

Practice location:
  • Phone: 770-639-1173
  • Fax:
Mailing address:
  • Phone: 770-639-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015217
License Number StateGA
# 2
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: