Healthcare Provider Details

I. General information

NPI: 1912357468
Provider Name (Legal Business Name): LORRAINE MIDDLETON ROSS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 DUNCAN DR BLDG 1440
SAVANNAH GA
31409-5107
US

IV. Provider business mailing address

230 DUNCAN DR BLDG 1440
SAVANNAH GA
31409-5107
US

V. Phone/Fax

Practice location:
  • Phone: 912-315-5417
  • Fax:
Mailing address:
  • Phone: 912-315-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH005049
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2844
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: