Provider Demographics
NPI:1053451377
Name:GORDON, ANITA S (DDS)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:S
Last Name:GORDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29411
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30359-0411
Mailing Address - Country:US
Mailing Address - Phone:404-486-7661
Mailing Address - Fax:404-486-7662
Practice Address - Street 1:2814 BUFORD HWY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2103
Practice Address - Country:US
Practice Address - Phone:404-486-7661
Practice Address - Fax:404-486-7662
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000225299AMedicaid
GA58-1458718OtherEIN