Provider Demographics
NPI:1417513730
Name:REZNIK, JORDAN ALEXANDER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ALEXANDER
Last Name:REZNIK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 STEWART DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1907
Mailing Address - Country:US
Mailing Address - Phone:404-406-1251
Mailing Address - Fax:
Practice Address - Street 1:236 PERIMETER CENTER PKWY NE STE C-30
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346-1402
Practice Address - Country:US
Practice Address - Phone:404-625-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015858390200000X
390200000X
GAD0158581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program