Healthcare Provider Details

I. General information

NPI: 1215086533
Provider Name (Legal Business Name): WEST GEORGIA ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 GENTIAN BLVD SUITE 2
COLUMBUS GA
31907-5687
US

IV. Provider business mailing address

3645 GENTIAN BLVD SUITE 2
COLUMBUS GA
31907-5687
US

V. Phone/Fax

Practice location:
  • Phone: 706-660-0221
  • Fax: 706-660-0132
Mailing address:
  • Phone: 706-660-0221
  • Fax: 706-660-0132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number012299
License Number StateGA

VIII. Authorized Official

Name: DR. PEGGY H AUGUSTINE
Title or Position: OWNER ORTHODONTIST
Credential: D.D.S., P.C.
Phone: 706-660-0221