Basic Information
| Provider Information | |||||||||
| NPI: | 1215487467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GORDON HIGHWAY DENTAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUGUSTA SMILES YOUTH DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 CHURCH ST STE 2210 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159882627 | ||||||||
| FaxNumber: | 6318577860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 GORDON HWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067909303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | ZOELLER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6159882627 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN015152 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.