1962830646 NPI number — SHELBY DENTAL CENTER

Table of content: (NPI 1962830646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962830646 NPI number — SHELBY DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY DENTAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHELBY DENTURE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962830646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 1105
Provider Second Line Business Mailing Address:
101 HWY 87, BLDG
Provider Business Mailing Address City Name:
CALERA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35040-7209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-664-1190
Provider Business Mailing Address Fax Number:
205-621-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HIGHWAY 87
Provider Second Line Business Practice Location Address:
BLDG 300
Provider Business Practice Location Address City Name:
CALERA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35040-7209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-664-1190
Provider Business Practice Location Address Fax Number:
205-621-6212
Provider Enumeration Date:
10/16/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
205-664-1190

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5208 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)