1568935286 NPI number — STATESBORO PEDIATRIC DENTISTRY, LLC

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 1568935286 NPI number — STATESBORO PEDIATRIC DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATESBORO PEDIATRIC DENTISTRY, LLC
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:
1568935286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 IRONGATE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30458-9195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-456-5907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 E GRADY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-456-5907
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
ANJALI
Authorized Official Middle Name:
PURI
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
478-456-5907

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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