Provider Demographics
NPI:1225255573
Name:CLELAND PERIODONTICS, PC
Entity Type:Organization
Organization Name:CLELAND PERIODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTICS
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CLELAND
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-423-5000
Mailing Address - Street 1:1605 HIGHWAY 34 E STE A
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2156
Mailing Address - Country:US
Mailing Address - Phone:678-423-5000
Mailing Address - Fax:678-423-5005
Practice Address - Street 1:1605 HIGHWAY 34 E STE A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2156
Practice Address - Country:US
Practice Address - Phone:678-423-5000
Practice Address - Fax:678-423-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty