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General NPI Number Information
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NPI Number | 1831372119
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Entity Type | Organization
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Legal Business Name | STATESBORO CHILDREN'S DENTAL CENTER, PC
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Dates
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Enumeration Date | 12/10/2007
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Last Update Date | 12/10/2007
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Provider Practice Location Address
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Address Line | 1501 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458-0856
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Country | US
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Telephone | 912-871-6197
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Fax | 912-871-6203
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Provider Business Mailing Address
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Address Line | 1501 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458-0856
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Country | US
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Telephone | 912-871-6197
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Fax | 912-871-6203
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN L WASDIN
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Credential | D.M.D.
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Telephone | 912-871-6197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN011889
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License Number State | GA
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