Provider Demographics
NPI:1487842951
Name:CONYERS DENTURES & IMPLANT CENTER
Entity type:Organization
Organization Name:CONYERS DENTURES & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CLELAND
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-483-4469
Mailing Address - Street 1:P.O. BOX 2213
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:770-483-4469
Mailing Address - Fax:770-922-0401
Practice Address - Street 1:1916 IRIS DRIVE, SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-483-4469
Practice Address - Fax:770-922-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126841223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty