Provider Demographics
NPI:1053696781
Name:TOWNE LAKE DENTAL GROUP, LLC
Entity type:Organization
Organization Name:TOWNE LAKE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-330-4545
Mailing Address - Street 1:125 SOUTHERN JUNCTION BLVD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2214
Mailing Address - Country:US
Mailing Address - Phone:912-330-4545
Mailing Address - Fax:
Practice Address - Street 1:125 SOUTHERN JUNCTION BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2214
Practice Address - Country:US
Practice Address - Phone:912-330-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA096171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty