Basic Information
| Provider Information | |||||||||
| NPI: | 1700430402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINS | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | NICOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38801 ACADEMIC DRIVE | ||||||||
| Address2: | SUITE B & C | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | BLDG 38801 ACADEMIC DRIVE | ||||||||
| Address2: | SUITE B & C | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 103807 | CA | Y | Dental Providers | Dentist |
No ID Information.