Provider Demographics
NPI:1578330197
Name:THE LEGACY DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:THE LEGACY DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BOOKOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-389-0638
Mailing Address - Street 1:4847 HIGH MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-8103
Mailing Address - Country:US
Mailing Address - Phone:912-389-0638
Mailing Address - Fax:
Practice Address - Street 1:444 N BELAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3002
Practice Address - Country:US
Practice Address - Phone:912-389-0638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty