Healthcare Provider Details

I. General information

NPI: 1649209859
Provider Name (Legal Business Name): FAIRCLOTH BAKEMAN PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 GEORGE C WILSON DR
AUGUSTA GA
30909-4502
US

IV. Provider business mailing address

1222 GEORGE C WILSON DR
AUGUSTA GA
30909-4502
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-9500
  • Fax: 706-868-5081
Mailing address:
  • Phone: 706-868-9500
  • Fax: 706-868-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. PAMELA S COCKRELL
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 706-868-9500