Organization
AUGUSTA SMILES YOUTH DENTISTRY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENELL STUMP (DIRECTOR, LICENSING & CREDENTIALING)
(706) 790-9302
Entity
Organization
Contact information
Practice address
1631 GORDON HWY, SUITE #22, AUGUSTA, GA 30906-2292
(706) 790-9302
(706) 790-9303
Mailing address
1631 GORDON HWY STE 22, AUGUSTA, GA 30906-2230
(706) 790-9302
(706) 790-9303
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1770568
UNITED CONCORDIA
GA
05
—
302137931A
—
GA
01
—
539114
AVESIS GA
GA
05
—
ZAG978
—
SC
Enumeration date
02/18/2006
Last updated
03/26/2015
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