=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609226448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP ANDREW JENKINS D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 HAWTHORN LN STE A
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-9203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-729-4748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2902 PATHVIEW LN
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-722-3186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | DN015173
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------