Healthcare Provider Details

I. General information

NPI: 1588674733
Provider Name (Legal Business Name): BORIS J SIDOW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3634 WHEELER ROAD
AUGUSTA GA
30909-6518
US

IV. Provider business mailing address

3634 WHEELER ROAD
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 NumberDN013478
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: