Provider Demographics
NPI:1396474458
Name:DOGWOOD PEDIATRIC DENTISTRY OF POOLER, LLC
Entity type:Organization
Organization Name:DOGWOOD PEDIATRIC DENTISTRY OF POOLER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-661-1391
Mailing Address - Street 1:203 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-1916
Mailing Address - Country:US
Mailing Address - Phone:912-661-1391
Mailing Address - Fax:
Practice Address - Street 1:100 BLUE MOON XING STE 105
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9809
Practice Address - Country:US
Practice Address - Phone:912-661-1391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-06
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty