Healthcare Provider Details

I. General information

NPI: 1053760058
Provider Name (Legal Business Name): CODY JAMES WHITWORTH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 JOHN WESLEY GILBER DRIVE
AUGUSTA GA
30912-0001
US

IV. Provider business mailing address

98 MILL RUN
NORTH AUGUSTA SC
29860-8704
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2371
  • Fax:
Mailing address:
  • Phone: 618-660-9715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.030680
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: