Provider Demographics
NPI:1437500220
Name:FORT STEWART DENTAC
Entity Type:Organization
Organization Name:FORT STEWART DENTAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:912-312-3352
Mailing Address - Street 1:343 WARRIOR ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:912-312-3352
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-312-3352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH0093632865X1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865X1600XHospitalsMilitary HospitalMilitary General Acute Care Hospital. Operational (Transportable)