Provider Demographics
NPI:1780888693
Name:JORDAN, TERESA DANIELLE (DMD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:DANIELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MILANO DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8381
Mailing Address - Country:US
Mailing Address - Phone:770-449-0836
Mailing Address - Fax:770-441-0299
Practice Address - Street 1:2646 GRESHAM RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-4148
Practice Address - Country:US
Practice Address - Phone:404-212-9060
Practice Address - Fax:404-212-9020
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA108964405Medicaid