Provider Demographics
NPI:1497205637
Name:EAST VICTORY DRIVE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:EAST VICTORY DRIVE DENTAL GROUP, LLC
Other - Org Name:SAVANNAH SMILES YOUTH DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-988-2627
Mailing Address - Street 1:401 CHURCH ST
Mailing Address - Street 2:SUITE 2210
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-2310
Mailing Address - Country:US
Mailing Address - Phone:615-988-2826
Mailing Address - Fax:631-857-7860
Practice Address - Street 1:2127 E VICTORY DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-3917
Practice Address - Country:US
Practice Address - Phone:912-443-6013
Practice Address - Fax:912-443-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0151521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty