MEDICARE: DR. ISAAC FAXON HOLTON JR. D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8610	GA

General Provider Information

NPI Number	:	1417039280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ISAAC FAXON HOLTON JR. D.M.D.

Provider Business Mailing Address
First Line	:	1214 W MEDICAL PARK RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4503
Country	:	US
Telephone Number	:	706-860-7937
Fax Number	:	706-860-9770

Provider Business Practice Location Address
First Line	:	1214 W MEDICAL PARK RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4503
Country	:	US
Telephone Number	:	706-860-7937
Fax Number	:	706-860-9770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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