Healthcare Provider Details

I. General information

NPI: 1790724763
Provider Name (Legal Business Name): SAMUEL CHRISTOPHER D'ARCO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 WALTON WAY EXT
AUGUSTA GA
30907-2402
US

IV. Provider business mailing address

3736 WALTON WAY EXT
AUGUSTA GA
30907-2402
US

V. Phone/Fax

Practice location:
  • Phone: 706-228-3100
  • Fax: 706-228-3707
Mailing address:
  • Phone: 706-228-3100
  • Fax: 706-228-3707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN011130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: