Provider Demographics
NPI:1609082122
Name:JOSE L. FAJARDO, D.M.D,P.C.
Entity Type:Organization
Organization Name:JOSE L. FAJARDO, D.M.D,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-368-1818
Mailing Address - Street 1:5720 BUFORD HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2577
Mailing Address - Country:US
Mailing Address - Phone:770-368-1818
Mailing Address - Fax:770-368-1618
Practice Address - Street 1:5720 BUFORD HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2577
Practice Address - Country:US
Practice Address - Phone:770-368-1818
Practice Address - Fax:770-368-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011347122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty