Provider Demographics
NPI:1861631053
Name:BRUNSON, JORDAN ALBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ALBERT
Last Name:BRUNSON
Suffix:
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 1:501 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
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice