Healthcare Provider Details

I. General information

NPI: 1215487467
Provider Name (Legal Business Name): GORDON HIGHWAY DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 GORDON HWY
AUGUSTA GA
30906
US

IV. Provider business mailing address

401 CHURCH ST STE 2210
NASHVILLE TN
37219-2204
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-9302
  • Fax: 706-790-9303
Mailing address:
  • Phone: 615-988-2627
  • Fax: 631-857-7860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015152
License Number StateGA

VIII. Authorized Official

Name: LINDA SUSAN ZOELLER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-988-2627