Basic Information
| Provider Information | |||||||||
| NPI: | 1346898293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGEPORT RIVER DENTAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709169000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1631 GORDON HWY STE 22 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067394706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | JACOMINO | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAYOR RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7709169000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0004X | N | 193200000X MULTI-SPECIALTY GROUP | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.