Organization
BRIDGEPORT RIVER DENTAL PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELLE JACOMINO (DIRECTOR OF PAYOR RELATIONS)
(770) 916-9000
Entity
Organization
Contact information
Practice address
1631 GORDON HWY STE 22, AUGUSTA, GA 30906-2230
(706) 790-9302
(706) 739-4706
Mailing address
1090 NORTHCHASE PKWY SE STE 150, MARIETTA, GA 30067-6407
(770) 916-9000
Taxonomy
Speciality
Code
Description
License number
State
1223D0004X
Dental Anesthesiology
—
—
1223E0200X
Endodontics
—
—
1223G0001X
General Practice Dentistry
Primary
—
—
1223P0221X
Pediatric Dentistry
—
—
1223P0300X
Periodontics
—
—
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
—
—
Other
Enumeration date
09/03/2019
Last updated
09/03/2019
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