Provider Demographics
NPI:1629851472
Name:PALMETTO FAMILY DENTAL OF FAYETTE COUNTY, PC
Entity Type:Organization
Organization Name:PALMETTO FAMILY DENTAL OF FAYETTE COUNTY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-580-9670
Mailing Address - Street 1:210 TRILITH PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4615
Mailing Address - Country:US
Mailing Address - Phone:706-580-9670
Mailing Address - Fax:
Practice Address - Street 1:210 TRILITH PKWY STE 130
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4615
Practice Address - Country:US
Practice Address - Phone:706-580-9670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty