Provider Demographics
NPI:1568935286
Name:STATESBORO PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:STATESBORO PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANJALI
Authorized Official - Middle Name:PURI
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-456-5907
Mailing Address - Street 1:101 IRONGATE PL
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9195
Mailing Address - Country:US
Mailing Address - Phone:478-456-5907
Mailing Address - Fax:
Practice Address - Street 1:613 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5104
Practice Address - Country:US
Practice Address - Phone:478-456-5907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty