Provider Demographics
NPI:1346898293
Name:BRIDGEPORT RIVER DENTAL PC
Entity Type:Organization
Organization Name:BRIDGEPORT RIVER DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-9000
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:770-916-9000
Mailing Address - Fax:
Practice Address - Street 1:1631 GORDON HWY STE 22
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2230
Practice Address - Country:US
Practice Address - Phone:706-790-9302
Practice Address - Fax:706-739-4706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty