1003046772 NPI number — ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.

Table of content: (NPI 1003046772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003046772 NPI number — ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.
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:
1003046772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 411714
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
629-999-5014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215C INDUSTRIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35983-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-526-7601
Provider Business Practice Location Address Fax Number:
256-526-7603
Provider Enumeration Date:
07/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EDMONDSON
Authorized Official First Name:
SHERRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, LICENSING & CREDENTIALING
Authorized Official Telephone Number:
629-999-5014

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112230 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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