Provider Demographics
NPI:1184738429
Name:POURNELLE, JOHN LOUIS JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:POURNELLE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:SOPERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30457-1160
Mailing Address - Country:US
Mailing Address - Phone:912-529-6171
Mailing Address - Fax:
Practice Address - Street 1:607 3RD ST N
Practice Address - Street 2:
Practice Address - City:SOPERTON
Practice Address - State:GA
Practice Address - Zip Code:30457-1160
Practice Address - Country:US
Practice Address - Phone:912-529-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0093681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00221064AMedicaid