Provider Demographics
NPI:1548616238
Name:BURGDORF, GRANT CHRISTIAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:CHRISTIAN
Last Name:BURGDORF
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 MT VERNON RD, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:559-361-4154
Mailing Address - Fax:
Practice Address - Street 1:1505 MT VERNON RD, SUITE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-396-7321
Practice Address - Fax:770-396-4936
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059402122300000X
GADN015915122300000X, 1223E0200X
IL019.030235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty