Healthcare Provider Details

I. General information

NPI: 1144231440
Provider Name (Legal Business Name): AUGUSTA ASSOCIATES OF ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 WHEELER ROAD
AUGUSTA GA
30909-1824
US

IV. Provider business mailing address

3502 WHEELER ROAD
AUGUSTA GA
30909-1824
US

V. Phone/Fax

Practice location:
  • Phone: 706-736-1406
  • Fax: 706-721-0706
Mailing address:
  • Phone: 706-736-1406
  • Fax: 706-721-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberGA8010
License Number StateGA

VIII. Authorized Official

Name: MR. BRIAN D OLSON
Title or Position: OWNER
Credential: DMD
Phone: 706-736-1406