Provider Demographics
NPI:1164793741
Name:SAVANNAH DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:SAVANNAH DENTAL GROUP, LLC
Other - Org Name:BRIAN BEAUDREAU, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-354-9204
Mailing Address - Street 1:5509 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4902
Mailing Address - Country:US
Mailing Address - Phone:912-354-9204
Mailing Address - Fax:
Practice Address - Street 1:5509 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4902
Practice Address - Country:US
Practice Address - Phone:912-354-9204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA096171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty