MEDICARE: GOLDEN ISLES ENDODONTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	DN013079	GA

General Provider Information

NPI Number	:	1710382007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN ISLES ENDODONTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 20067
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-8067
Country	:	US
Telephone Number	:	912-268-2800
Fax Number	:	912-434-9936

Provider Business Practice Location Address
First Line	:	1804 FREDERICA RD STE B
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-2044
Country	:	US
Telephone Number	:	912-268-2800
Fax Number	:	912-434-9936

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER LEA
Credential	:	DDS
Telephone Number	:	912-756-5960

Provider Enumeration Date	:	10/29/2014
Last Update Date	:	10/29/2014

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