Provider Demographics
NPI:1831372119
Name:STATESBORO CHILDREN'S DENTAL CENTER, PC
Entity type:Organization
Organization Name:STATESBORO CHILDREN'S DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WASDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-871-6197
Mailing Address - Street 1:1501 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0856
Mailing Address - Country:US
Mailing Address - Phone:912-871-6197
Mailing Address - Fax:912-871-6203
Practice Address - Street 1:1501 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0856
Practice Address - Country:US
Practice Address - Phone:912-871-6197
Practice Address - Fax:912-871-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011889261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental