Organization
SOUTHWEST MAXILLOFACIAL SURGERY & IMPLANT CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACQUES LEONEL GORDON DMD (PRESIDENT)
(404) 629-6610
Entity
Organization
Contact information
Practice address
3885 PRINCETON LAKES WAY SW, 406, ATLANTA, GA 30331-5589
(404) 629-6610
(404) 629-6630
Mailing address
3885 PRINCETON LAKES WAY SW, 406, ATLANTA, GA 30331-5589
(404) 629-6610
(404) 629-6630
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DN013463
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
457061566A
—
GA
Enumeration date
07/15/2009
Last updated
07/15/2009
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