Provider Demographics
NPI:1538571435
Name:ORAL SURGERY OF WEST AUGUSTA PC
Entity type:Organization
Organization Name:ORAL SURGERY OF WEST AUGUSTA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIDOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-860-8228
Mailing Address - Street 1:3634 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6518
Mailing Address - Country:US
Mailing Address - Phone:706-860-8228
Mailing Address - Fax:706-860-7222
Practice Address - Street 1:3634 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6518
Practice Address - Country:US
Practice Address - Phone:706-860-8228
Practice Address - Fax:706-860-7222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013478204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000848645OtherTRICARE ACTIVE DUTY DENTAL PLAN
000425742OtherTRICARE ACTIVE DUTY DENTAL PLAN
GA111331508BMedicaid
GA000056438CMedicaid
002068046OtherTRICARE ACTIVE DUTY DENTAL PLAN
GA000056427CMedicaid
GA000056427CMedicaid
GA202I195418Medicare PIN
GA70055919DAMedicare PIN
000848645OtherTRICARE ACTIVE DUTY DENTAL PLAN
GA111331508BMedicaid