Provider Demographics
NPI:1619901808
Name:AUGUSTA DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:AUGUSTA DENTAL ASSOCIATES, LLC
Other - Org Name:MICHAEL O. VERNON, DMD, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MOLDOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-860-0518
Mailing Address - Street 1:1218 AUGUSTA WEST PARKWAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1808
Mailing Address - Country:US
Mailing Address - Phone:706-860-0518
Mailing Address - Fax:706-860-4902
Practice Address - Street 1:1218 AUGUSTA WEST PARKWAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1808
Practice Address - Country:US
Practice Address - Phone:706-860-0518
Practice Address - Fax:706-860-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123771223G0001X
GA88151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00922655AMedicaid
GA00137948BMedicaid