Healthcare Provider Details

I. General information

NPI: 1548345036
Provider Name (Legal Business Name): DONALD J PAYNE DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 NW BROAD ST
LYONS GA
30436-0899
US

IV. Provider business mailing address

PO BOX 899
LYONS GA
30436-0899
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-6616
  • Fax: 912-526-6616
Mailing address:
  • Phone: 912-526-6616
  • Fax: 912-526-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN008209
License Number StateGA

VIII. Authorized Official

Name: DR. DONALD J PAYNE
Title or Position: PRESIDENT
Credential: DMD
Phone: 912-526-6616