Provider Demographics
NPI:1396403051
Name:INNOVATIVE ORTHO GROUP LLC
Entity Type:Organization
Organization Name:INNOVATIVE ORTHO GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONIHUE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-660-3706
Mailing Address - Street 1:9100 WHITE BLUFF RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4673
Mailing Address - Country:US
Mailing Address - Phone:912-354-3474
Mailing Address - Fax:
Practice Address - Street 1:9100 WHITE BLUFF RD STE 104
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4673
Practice Address - Country:US
Practice Address - Phone:912-354-3474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty