1841265451 NPI number — SAVANNAH SMILES YOUTH DENTISTRY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841265451 NPI number — SAVANNAH SMILES YOUTH DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAVANNAH SMILES YOUTH DENTISTRY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841265451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2127 E VICTORY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31404-3917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-443-6013
Provider Business Mailing Address Fax Number:
912-443-6014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2127 E VICTORY DR
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31404-3917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-443-6013
Provider Business Practice Location Address Fax Number:
912-443-6014
Provider Enumeration Date:
02/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STUMP
Authorized Official First Name:
JENELL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, LICENSING & CREDENTIALING
Authorized Official Telephone Number:
912-443-6013

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 539121 . This is a "AVESIS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: ZAG977 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1888552 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 401680528A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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