Healthcare Provider Details

I. General information

NPI: 1457541781
Provider Name (Legal Business Name): AU DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 JOHN WESLEY GILBERT DRIVE
AUGUSTA GA
30912-1001
US

IV. Provider business mailing address

1430 JOHN WESLEY GILBERT DRIVE GC-1012
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2371
  • Fax:
Mailing address:
  • Phone: 706-721-7913
  • Fax: 706-721-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number000179
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DARRELL GENTRY
Title or Position: ASSOCIATE DEAN, FINANCE / BUSINESS
Credential:
Phone: 706-721-2103