Basic Information
| Provider Information | |||||||||
| NPI: | 1215591664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGESON | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 961 BADGER CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539252109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207632877 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1126 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029197109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013512750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2019 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN1858294 | MA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DEN0357 | RI | Y | Dental Providers | Dentist | General Practice |
No ID Information.