Provider Demographics
NPI:1457541781
Name:AU DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:AU DENTAL ASSOCIATES
Other - Org Name:AU DENTAL ASSOCIATES DENTAL COLLEGE OF GA
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE DEAN, FINANCE / BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-721-2103
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE GC-1012
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-7913
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-2371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000179122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty