Organization
ORAL SURGERY OF WEST AUGUSTA PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BORIS J SIDOW D.D.S. (OWNER SURGEON)
(706) 860-8228
Entity
Organization
Contact information
Practice address
3634 WHEELER RD, AUGUSTA, GA 30909-6518
(706) 860-8228
(706) 860-7222
Mailing address
3634 WHEELER RD, AUGUSTA, GA 30909-6518
(706) 860-8228
(706) 860-7222
Taxonomy
Speciality
Code
Description
License number
State
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
DN013478
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000056427C
—
GA
05
—
000056438C
—
GA
01
—
000425742
TRICARE ACTIVE DUTY DENTAL PLAN
—
01
—
000848645
TRICARE ACTIVE DUTY DENTAL PLAN
—
01
—
002068046
TRICARE ACTIVE DUTY DENTAL PLAN
—
05
—
111331508B
—
GA
Enumeration date
05/27/2014
Last updated
05/27/2014
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