Provider Demographics
NPI:1497260145
Name:BRUNSWICK DENTISTY LLC
Entity Type:Organization
Organization Name:BRUNSWICK DENTISTY LLC
Other - Org Name:BRUNSWICK SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-262-1081
Mailing Address - Street 1:4741 ALTAMA AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-2910
Mailing Address - Country:US
Mailing Address - Phone:912-262-1081
Mailing Address - Fax:
Practice Address - Street 1:4741 ALTAMA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2910
Practice Address - Country:US
Practice Address - Phone:912-262-1081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty