Provider Demographics
NPI:1104128263
Name:SGPC, PC
Entity type:Organization
Organization Name:SGPC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:229-247-3200
Mailing Address - Street 1:3227 N OAK STREET EXT
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7416
Mailing Address - Country:US
Mailing Address - Phone:229-247-3200
Mailing Address - Fax:
Practice Address - Street 1:3227 N OAK STREET EXT
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7416
Practice Address - Country:US
Practice Address - Phone:229-247-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0149761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA102640352AMedicaid
GA00917067BMedicaid
GA003162889BMedicaid