Provider Demographics
NPI:1194981910
Name:SOUTH GEORGIA PERIODONTICS, PC
Entity type:Organization
Organization Name:SOUTH GEORGIA PERIODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEPTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-247-0437
Mailing Address - Street 1:307 GEORGETOWN CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4113
Mailing Address - Country:US
Mailing Address - Phone:229-247-0437
Mailing Address - Fax:229-242-4395
Practice Address - Street 1:307 GEORGETOWN CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-4113
Practice Address - Country:US
Practice Address - Phone:229-247-0437
Practice Address - Fax:229-242-4395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty