| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 155 Trader Way, Pooler, Georgia |
| Authorized Official Name and Position | Kendra Walker (CREDENTIALING COORDINATOR) |
| Authorized Official Contact | 2175408312 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
155 Traders Way Suite 400 Pooler GA 31322-4300 Ph: (912) 348-3155 | 155 Trader Way Pooler GA 31322 Ph: (912) 208-5594 |
| NPI Number | 1396135216 |
|---|---|
| Provider Enumeration Date | 01/30/2015 |
| Last Update Date | 05/25/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396135216 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | DN012289 (Georgia) | Primary |
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