Provider Demographics
NPI:1003958638
Name:ST. SIMONS ISLAND DENTAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:ST. SIMONS ISLAND DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-638-9921
Mailing Address - Street 1:2487 DEMERE RD STE 100
Mailing Address - Street 2:PO BOX 20326
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5640
Mailing Address - Country:US
Mailing Address - Phone:912-638-9921
Mailing Address - Fax:912-638-4121
Practice Address - Street 1:2487 DEMERE RD
Practice Address - Street 2:STE 100
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-5639
Practice Address - Country:US
Practice Address - Phone:912-638-9921
Practice Address - Fax:912-638-4121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011726122300000X
GADN012532122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty