=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255419446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER BANNOUT DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 CANAL ST SUITE 204
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-4085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-748-5868
-----------------------------------------------------
Fax | 912-748-6778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 CANAL ST SUITE 204
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-4085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-748-5868
-----------------------------------------------------
Fax | 912-748-6778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN013382
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901019341
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------