Provider Demographics
NPI:1841265451
Name:SAVANNAH SMILES YOUTH DENTISTRY, PC
Entity type:Organization
Organization Name:SAVANNAH SMILES YOUTH DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-443-6013
Mailing Address - Street 1:2127 E VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-3917
Mailing Address - Country:US
Mailing Address - Phone:912-443-6013
Mailing Address - Fax:912-443-6014
Practice Address - Street 1:2127 E VICTORY DR
Practice Address - Street 2:SUITE #2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-3917
Practice Address - Country:US
Practice Address - Phone:912-443-6013
Practice Address - Fax:912-443-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-18
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA539121OtherAVESIS
SCZAG977Medicaid
GA1888552OtherUNITED CONCORDIA
GA401680528AMedicaid