Provider Demographics
NPI:1255419446
Name:BANNOUT, ALEXANDER (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:BANNOUT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CANAL ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4085
Mailing Address - Country:US
Mailing Address - Phone:912-748-5868
Mailing Address - Fax:912-748-6778
Practice Address - Street 1:130 CANAL ST
Practice Address - Street 2:SUITE 204
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4085
Practice Address - Country:US
Practice Address - Phone:912-748-5868
Practice Address - Fax:912-748-6778
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133821223G0001X
MI29010193411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice