Healthcare Provider Details

I. General information

NPI: 1548205636
Provider Name (Legal Business Name): DRS. PEACOCK & RAFOTH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

IV. Provider business mailing address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

V. Phone/Fax

Practice location:
  • Phone: 706-860-8228
  • Fax: 706-860-7222
Mailing address:
  • Phone: 706-860-8228
  • Fax: 706-860-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN007367
License Number StateGA

VIII. Authorized Official

Name: CLAIRE SHIVERS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 706-860-8228