Provider Demographics
NPI:1881766160
Name:GORDON B BURNETT DDS PC
Entity type:Organization
Organization Name:GORDON B BURNETT DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS PC PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-997-4598
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0072881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty