Healthcare Provider Details

I. General information

NPI: 1457509622
Provider Name (Legal Business Name): ANGELA BONITA RECHEDY C.D.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2008
Last Update Date: 08/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD AD 2307
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

4467 SHADOWMOOR DR
MARTINEZ GA
30907-4508
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2811
  • Fax:
Mailing address:
  • Phone: 706-868-5186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number111463
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: