Provider Demographics
NPI:1639269038
Name:ENDODONTIC ASSOCIATES OF SAVANNAH PC
Entity Type:Organization
Organization Name:ENDODONTIC ASSOCIATES OF SAVANNAH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-355-7790
Mailing Address - Street 1:316 STEPHENSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-355-7790
Mailing Address - Fax:912-351-9546
Practice Address - Street 1:316 STEPHENSON AVENUE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-355-7790
Practice Address - Fax:912-351-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100501223E0200X
GA100491223E0200X
GADN0137201223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty