=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942868450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN PEARL DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2019
-----------------------------------------------------
Last Update Date | 05/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1883 MCDONOUGH RD
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-729-5159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 SHORELINE DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30215-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LATONYA GILLESPIE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 404-729-5159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------