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General NPI Number Information
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NPI Number | 1033184643
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Entity Type | Organization
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Legal Business Name | AUGUSTA SMILES YOUTH DENTISTRY, PC
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Dates
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Enumeration Date | 02/18/2006
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Last Update Date | 03/26/2015
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Provider Practice Location Address
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Address Line | 1631 GORDON HWY SUITE #22
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City | AUGUSTA
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State | GA
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Zip | 30906-2292
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Country | US
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Telephone | 706-790-9302
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Fax | 706-790-9303
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Provider Business Mailing Address
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Address Line | 1631 GORDON HWY STE 22
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City | AUGUSTA
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State | GA
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Zip | 30906-2230
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Country | US
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Telephone | 706-790-9302
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Fax | 706-790-9303
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Authorized Official
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Title or Position | DIRECTOR, LICENSING & CREDENTIALING
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Name | MRS. JENELL STUMP
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Credential |
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Telephone | 706-790-9302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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