Healthcare Provider Details

I. General information

NPI: 1770132581
Provider Name (Legal Business Name): AUBURN PERIODONTICS OF COLUMBUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BROOKSTONE CENTRE PKWY STE 100
COLUMBUS GA
31904-3640
US

IV. Provider business mailing address

400 BROOKSTONE CENTRE PKWY STE 100
COLUMBUS GA
31904-3640
US

V. Phone/Fax

Practice location:
  • Phone: 706-222-7149
  • Fax:
Mailing address:
  • Phone: 706-222-7149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. BRITANY FABIAN MATIN
Title or Position: PRESIDENT, CEO
Credential: DMD
Phone: 334-444-0571