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General NPI Number Information
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NPI Number | 1831637644
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Entity Type | Organization
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Legal Business Name | PURPLE DENTAL LLC
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Dates
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Enumeration Date | 02/01/2017
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Last Update Date | 02/01/2017
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Provider Practice Location Address
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Address Line | 1609 NORMAN DR STE B
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City | VALDOSTA
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State | GA
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Zip | 31601-3753
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Country | US
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Telephone | 229-269-4607
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Fax | 229-244-6701
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Provider Business Mailing Address
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Address Line | PO BOX 3189
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City | SYRACUSE
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State | NY
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Zip | 13220-3189
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Country | US
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Telephone | 315-454-6000
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Fax |
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Authorized Official
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Title or Position | PROVIDER RELATIONS
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Name | JENNIFER LA DUC
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Credential |
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Telephone | 315-454-6000
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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 |
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License Number State |
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