Provider Demographics
NPI:1942868450
Name:SOUTHERN PEARL DENTISTRY
Entity Type:Organization
Organization Name:SOUTHERN PEARL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-729-5159
Mailing Address - Street 1:210 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-4665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1883 MCDONOUGH RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-3516
Practice Address - Country:US
Practice Address - Phone:404-729-5159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty