1871360685 NPI number — THRIVE FAMILY DENTISTRY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871360685 NPI number — THRIVE FAMILY DENTISTRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE FAMILY DENTISTRY, LLC
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:
Provider Other Organization Name Type Code:
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:
1871360685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1708 CARRIAGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHENIX CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36867-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-580-6546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 SAMFORD TRACE COURT
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-580-6546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
RACHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
706-580-6546

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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