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General NPI Number Information
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NPI Number | 1053696781
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Entity Type | Organization
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Legal Business Name | TOWNE LAKE DENTAL GROUP, LLC
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Dates
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Enumeration Date | 10/13/2011
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Last Update Date | 10/13/2011
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Provider Practice Location Address
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Address Line | 125 SOUTHERN JUNCTION BLVD SUITE 701
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City | POOLER
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State | GA
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Zip | 31322-2214
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Country | US
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Telephone | 912-330-4545
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Fax |
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Provider Business Mailing Address
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Address Line | 125 SOUTHERN JUNCTION BLVD SUITE 701
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City | POOLER
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State | GA
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Zip | 31322-2214
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Country | US
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Telephone | 912-330-4545
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. BRIAN BEAUDREAU
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Credential | D.M.D.
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Telephone | 912-330-4545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 09617
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License Number State | GA
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