Healthcare Provider Details

I. General information

NPI: 1497546162
Provider Name (Legal Business Name): CRYSTAL SORG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E LONG ST
CLAXTON GA
30417-1409
US

IV. Provider business mailing address

201 E LONG ST
CLAXTON GA
30417-1409
US

V. Phone/Fax

Practice location:
  • Phone: 912-739-1595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124156
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: