Provider Demographics
NPI:1841580560
Name:PALMETTO FAMILY DENTAL, PC
Entity Type:Organization
Organization Name:PALMETTO FAMILY DENTAL, PC
Other - Org Name:JORDAN A. BRUNSON, DDS, OC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-463-4541
Mailing Address - Street 1:501 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1007
Mailing Address - Country:US
Mailing Address - Phone:770-463-4541
Mailing Address - Fax:770-463-9184
Practice Address - Street 1:501 PARK ST
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1007
Practice Address - Country:US
Practice Address - Phone:770-463-4541
Practice Address - Fax:770-463-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty