1538571435 NPI number — ORAL SURGERY OF WEST AUGUSTA PC

Table of content: (NPI 1538571435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538571435 NPI number — ORAL SURGERY OF WEST AUGUSTA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL SURGERY OF WEST AUGUSTA PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538571435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3634 WHEELER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-6518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-860-8228
Provider Business Mailing Address Fax Number:
706-860-7222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3634 WHEELER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-860-8228
Provider Business Practice Location Address Fax Number:
706-860-7222
Provider Enumeration Date:
05/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SIDOW
Authorized Official First Name:
BORIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER SURGEON
Authorized Official Telephone Number:
706-860-8228

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  DN013478 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000848645 . This is a "TRICARE ACTIVE DUTY DENTAL PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000425742 . This is a "TRICARE ACTIVE DUTY DENTAL PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111331508B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000056438C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002068046 . This is a "TRICARE ACTIVE DUTY DENTAL PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000056427C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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