Provider Demographics
NPI:1215086533
Name:WEST GEORGIA ORTHODONTICS
Entity type:Organization
Organization Name:WEST GEORGIA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:H
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:706-660-0221
Mailing Address - Street 1:3645 GENTIAN BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5687
Mailing Address - Country:US
Mailing Address - Phone:706-660-0221
Mailing Address - Fax:706-660-0132
Practice Address - Street 1:3645 GENTIAN BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-5687
Practice Address - Country:US
Practice Address - Phone:706-660-0221
Practice Address - Fax:706-660-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0122991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty