Active NPI
Gina Wallace
- Dental Hygienist
- Brunswick, GA
National Provider Identifier
1417699505
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dental Hygienist
- License
- DH043989
- Practice address
- 4741 Altama Ave
Brunswick, GA 31520-2910 - Phone
- (912) 262-1081
- NPI assigned
- Apr 10, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dental Hygienist | 124Q00000X | DH043989 | GA | Primary |
Addresses
Primary practice location
4741 Altama Ave
Brunswick, GA 31520-2910
Mailing address
4741 Altama Ave
Brunswick, GA 31520-2910
Phone (912) 262-1081
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DH043989 | GA | MD | Dental Hygienist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Brunswick Dentisty LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1649548800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1649548800000",
"number": "1417699505",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4741 ALTAMA AVE",
"city": "BRUNSWICK",
"state": "GA",
"postal_code": "315202910",
"telephone_number": "912-262-1081"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4741 ALTAMA AVE",
"city": "BRUNSWICK",
"state": "GA",
"postal_code": "315202910",
"telephone_number": "912-262-1081"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "GINA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-04-10",
"last_updated": "2022-04-10",
"certification_date": "2022-04-10",
"status": "A"
},
"taxonomies": [
{
"code": "124Q00000X",
"taxonomy_group": "",
"desc": "Dental Hygienist",
"state": "GA",
"license": "DH043989",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Brunswick, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.