Provider Demographics
NPI:1528435203
Name:ANITA S. GODON DDS
Entity type:Organization
Organization Name:ANITA S. GODON DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-486-7661
Mailing Address - Street 1:PO BOX 29411
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30359-0411
Mailing Address - Country:US
Mailing Address - Phone:404-486-7661
Mailing Address - Fax:404-486-7662
Practice Address - Street 1:2814 BUFORD HWY NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2103
Practice Address - Country:US
Practice Address - Phone:404-486-7661
Practice Address - Fax:404-486-7662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000225299AMedicaid
GA00809278AMedicaid