Healthcare Provider Details

I. General information

NPI: 1730083239
Provider Name (Legal Business Name): JL POURNELLE JR DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5580 N THIRD ST
SOPERTON GA
30457-2007
US

IV. Provider business mailing address

5580 N THIRD ST
SOPERTON GA
30457-2007
US

V. Phone/Fax

Practice location:
  • Phone: 912-529-6171
  • Fax: 912-529-6500
Mailing address:
  • Phone: 912-529-6171
  • Fax: 912-529-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JOHN LOUIS POURNELLE JR.
Title or Position: PRESIDENT
Credential: DMD
Phone: 912-529-6172