Healthcare Provider Details

I. General information

NPI: 1275175309
Provider Name (Legal Business Name): FIRST CITY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 11/10/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TOWNE CENTER BLVD BLDG 100 STE 101
POOLER GA
31322-4508
US

IV. Provider business mailing address

1000 TOWNE CENTER BLVD BLDG 100, STE 101
POOLER GA
31322-4508
US

V. Phone/Fax

Practice location:
  • Phone: 912-385-4134
  • Fax:
Mailing address:
  • Phone: 912-385-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW J ALLEN
Title or Position: OWNER
Credential: DDS
Phone: 912-385-4134