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General NPI Number Information
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NPI Number | 1477859387
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Entity Type | Organization
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Legal Business Name | SWEETGUMS DENTAL LLC
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Dates
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Enumeration Date | 02/10/2011
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Last Update Date | 02/10/2011
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Provider Practice Location Address
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Address Line | 1435 54TH ST SUITE 100A
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City | COLUMBUS
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State | GA
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Zip | 31904-4998
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Country | US
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Telephone | 706-507-9132
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Fax | 706-507-9135
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Provider Business Mailing Address
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Address Line | 1435 54TH ST SUITE 100A
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City | COLUMBUS
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State | GA
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Zip | 31904-4998
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Country | US
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Telephone | 706-507-9132
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Fax | 706-507-9135
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | LARETHA URETT LOCKHART
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Credential | DDS
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Telephone | 706-507-9132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN013438
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License Number State | GA
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