Healthcare Provider Details

I. General information

NPI: 1982917522
Provider Name (Legal Business Name): ALEXANDER BANNOUT DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2010
Last Update Date: 07/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CANAL ST SUITE 204
POOLER GA
31322-4085
US

IV. Provider business mailing address

130 CANAL ST SUITE 204
POOLER GA
31322-4085
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-5868
  • Fax: 912-748-6778
Mailing address:
  • Phone: 912-748-5868
  • Fax: 912-748-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013382
License Number StateGA

VIII. Authorized Official

Name: DR. ALEXANDER BANNOUT
Title or Position: DENTIST
Credential: DDS
Phone: 248-890-7347