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General NPI Number Information
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NPI Number | 1437500220
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Entity Type | Organization
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Legal Business Name | FORT STEWART DENTAC
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Dates
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Enumeration Date | 06/23/2016
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Last Update Date | 06/23/2016
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Provider Practice Location Address
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Address Line | 1061 HARMON AVE
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City | FORT STEWART
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State | GA
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Zip | 31314-5641
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Country | US
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Telephone | 912-312-3352
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Fax |
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Provider Business Mailing Address
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Address Line | 343 WARRIOR ROAD
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City | FORT STEWART
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State | GA
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Zip | 31314
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Country | US
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Telephone | 912-312-3352
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Fax |
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Authorized Official
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Title or Position | REGISTERED DENTAL HYGIENIST
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Name | GLENDA ANN WITHERS
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Credential | RDH
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Telephone | 912-312-3352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2865X1600X
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Taxonomy Name | Operational (Transportable) Military General Acute Care Hospital
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License Number | DH009363
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License Number State | GA
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