Provider Demographics
NPI:1013778042
Name:SOUTH PORT DENTISTRY
Entity Type:Organization
Organization Name:SOUTH PORT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAVANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-207-0223
Mailing Address - Street 1:288 REDFERN VLG
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2536
Mailing Address - Country:US
Mailing Address - Phone:912-638-9090
Mailing Address - Fax:
Practice Address - Street 1:200 HYDE PARK CMNS
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31523-6601
Practice Address - Country:US
Practice Address - Phone:912-342-8404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental