Basic Information
| Provider Information | |||||||||
| NPI: | 1033184643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUGUSTA SMILES YOUTH DENTISTRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 GORDON HWY STE 22 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067909303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 GORDON HWY | ||||||||
| Address2: | SUITE #22 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067909303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | STUMP | ||||||||
| AuthorizedOfficialFirstName: | JENELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, LICENSING & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7067909302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1770568 | 01 | GA | UNITED CONCORDIA | OTHER | 302137931A | 05 | GA | MEDICAID | ZAG978 | 05 | SC | MEDICAID | 539114 | 01 | GA | AVESIS GA | OTHER |