Provider Demographics
NPI:1265921837
Name:SOUTHLAND CHILDRENS DENTISTRY VALDOSTA, LLC
Entity type:Organization
Organization Name:SOUTHLAND CHILDRENS DENTISTRY VALDOSTA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-247-3200
Mailing Address - Street 1:3227 N OAK STREET EXT STE A
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7415
Mailing Address - Country:US
Mailing Address - Phone:229-247-3200
Mailing Address - Fax:229-241-1900
Practice Address - Street 1:3227 N OAK STREET EXT STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7415
Practice Address - Country:US
Practice Address - Phone:229-247-3200
Practice Address - Fax:229-241-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0148131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty