Provider Demographics
NPI:1073743795
Name:SOUTHWEST MAXILLOFACIAL SURGERY & IMPLANT CENTER
Entity Type:Organization
Organization Name:SOUTHWEST MAXILLOFACIAL SURGERY & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUES
Authorized Official - Middle Name:LEONEL
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-629-6610
Mailing Address - Street 1:3885 PRINCETON LAKES WAY SW
Mailing Address - Street 2:406
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5589
Mailing Address - Country:US
Mailing Address - Phone:404-629-6610
Mailing Address - Fax:404-629-6630
Practice Address - Street 1:3885 PRINCETON LAKES WAY SW
Practice Address - Street 2:406
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5589
Practice Address - Country:US
Practice Address - Phone:404-629-6610
Practice Address - Fax:404-629-6630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA457061566AMedicaid