Healthcare Provider Details

I. General information

NPI: 1114707767
Provider Name (Legal Business Name): KELLY STEVENS AGUILAR RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 TELFAIR ST
AUGUSTA GA
30901-2590
US

IV. Provider business mailing address

202 ANNIE LAURIE DR
GROVETOWN GA
30813-4109
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH043361
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: