1598140600 NPI number — GOLDEN ISLES PEDIATRIC DENTISTRY

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 1598140600 NPI number — GOLDEN ISLES PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN ISLES PEDIATRIC DENTISTRY
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:
1598140600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2475 VILLAGE DR
Provider Second Line Business Mailing Address:
SUITE 114
Provider Business Mailing Address City Name:
KINGSLAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31548-6728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-882-4040
Provider Business Mailing Address Fax Number:
912-882-3514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2475 VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
KINGSLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31548-6728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-882-4040
Provider Business Practice Location Address Fax Number:
912-882-3514
Provider Enumeration Date:
07/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
912-882-4040

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DN012985 , 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)





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