1548473754 NPI number — SOUTHERN ORTHODONTICS

Table of content: (NPI 1548473754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548473754 NPI number — SOUTHERN ORTHODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ORTHODONTICS
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:
1548473754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 LONG LEAF OFFICE PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOULTRIE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31768-6780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-985-4715
Provider Business Mailing Address Fax Number:
229-985-0997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 LONG LEAF OFFICE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOULTRIE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31768-6780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-985-4715
Provider Business Practice Location Address Fax Number:
229-985-0997
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
J
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
229-985-4715

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  11208 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11208 . This is a "DENTAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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