Healthcare Provider Details

I. General information

NPI: 1538571435
Provider Name (Legal Business Name): ORAL SURGERY OF WEST AUGUSTA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

IV. Provider business mailing address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

V. Phone/Fax

Practice location:
  • Phone: 706-860-8228
  • Fax: 706-860-7222
Mailing address:
  • Phone: 706-860-8228
  • Fax: 706-860-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN013478
License Number StateGA

VIII. Authorized Official

Name: DR. BORIS J SIDOW
Title or Position: OWNER SURGEON
Credential: D.D.S.
Phone: 706-860-8228