Healthcare Provider Details

I. General information

NPI: 1861670143
Provider Name (Legal Business Name): AUGUSTA ORAL SURGERY SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 10/30/2012
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: SAMUEL C D'ARCO
Title or Position: OWNER
Credential: DDS
Phone: 706-228-3100