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General NPI Number Information
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NPI Number | 1396474458
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Entity Type | Organization
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Legal Business Name | DOGWOOD PEDIATRIC DENTISTRY OF POOLER, LLC
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 06/16/2022
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Provider Practice Location Address
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Address Line | 100 BLUE MOON XING STE 105
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City | POOLER
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State | GA
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Zip | 31322-9809
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Country | US
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Telephone | 912-661-1391
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Fax |
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Provider Business Mailing Address
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Address Line | 203 COMMONWEALTH AVE
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City | PORT WENTWORTH
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State | GA
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Zip | 31407-1916
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Country | US
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Telephone | 912-661-1391
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KAREN STEVENS
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Credential |
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Telephone | 912-661-1391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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