Healthcare Provider Details

I. General information

NPI: 1003958638
Provider Name (Legal Business Name): ST. SIMONS ISLAND DENTAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2487 DEMERE RD STE 100
ST SIMONS ISLAND GA
31522-5639
US

IV. Provider business mailing address

2487 DEMERE RD STE 100 PO BOX 20326
ST SIMONS ISLAND GA
31522-5640
US

V. Phone/Fax

Practice location:
  • Phone: 912-638-9921
  • Fax: 912-638-4121
Mailing address:
  • Phone: 912-638-9921
  • Fax: 912-638-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN011726
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN012532
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: PAUL E THOMPSON
Title or Position: DENTIST
Credential: DMD
Phone: 912-638-9921