Provider Demographics
NPI:1033184643
Name:AUGUSTA SMILES YOUTH DENTISTRY, PC
Entity Type:Organization
Organization Name:AUGUSTA SMILES YOUTH DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-790-9302
Mailing Address - Street 1:1631 GORDON HWY STE 22
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2230
Mailing Address - Country:US
Mailing Address - Phone:706-790-9302
Mailing Address - Fax:706-790-9303
Practice Address - Street 1:1631 GORDON HWY
Practice Address - Street 2:SUITE #22
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2292
Practice Address - Country:US
Practice Address - Phone:706-790-9302
Practice Address - Fax:706-790-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-18
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1770568OtherUNITED CONCORDIA
GA302137931AMedicaid
SCZAG978Medicaid
GA539114OtherAVESIS GA