Provider Demographics
NPI:1124423934
Name:FAJARDO, JOSE (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 BUFORD HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2577
Mailing Address - Country:US
Mailing Address - Phone:770-368-1818
Mailing Address - Fax:
Practice Address - Street 1:5720 BUFORD HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2577
Practice Address - Country:US
Practice Address - Phone:770-368-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011347122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist