Healthcare Provider Details

I. General information

NPI: 1215981352
Provider Name (Legal Business Name): HARRY NICK BOBOTIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 VILSECK ROAD BLDG 419-2
FORT STEWART GA
31315
US

IV. Provider business mailing address

112 VILSECK ROAD BLDG 419-2
FORT STEWART GA
31315
US

V. Phone/Fax

Practice location:
  • Phone: 912-257-7056
  • Fax: 912-257-7055
Mailing address:
  • Phone: 912-257-7056
  • Fax: 912-257-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN011989
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3490
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: