Provider Demographics
NPI:1134203219
Name:BURNETT, GORDON BERRY SR (DDS)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:BERRY
Last Name:BURNETT
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 PHOENIX BLVD
Mailing Address - Street 2:SUITE 148
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5533
Mailing Address - Country:US
Mailing Address - Phone:770-997-4598
Mailing Address - Fax:770-997-6944
Practice Address - Street 1:1895 PHOENIX BLVD
Practice Address - Street 2:SUITE 148
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5533
Practice Address - Country:US
Practice Address - Phone:770-997-4598
Practice Address - Fax:770-997-6944
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0072881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice