=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578330197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LEGACY DENTAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 N BELAIR RD STE 101
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-218-2186
-----------------------------------------------------
Fax | 762-200-2302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4847 HIGH MEADOWS DR
-----------------------------------------------------
City | GROVETOWN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30813-8103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-389-0638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JONATHAN KEITH BOOKOUT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 912-389-0638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------