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General NPI Number Information
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NPI Number | 1033893797
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Entity Type | Organization
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Legal Business Name | ELEMENT DENTAL GROUP LLC
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Dates
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Enumeration Date | 06/13/2023
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Last Update Date | 09/14/2023
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Provider Practice Location Address
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Address Line | 3456 WRIGHTSBORO RD
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City | AUGUSTA
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State | GA
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Zip | 30909-2678
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Country | US
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Telephone | 706-251-7917
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 70887
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City | CLEVELAND
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State | OH
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Zip | 44190-0887
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR CREDENTIALING & ENROLLMENT
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Name | MICHELLE JACOMINO-BARNES
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Credential |
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Telephone | 813-270-9497
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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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