Basic Information
| Provider Information | |||||||||
| NPI: | 1134421746 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VITAL SMILES ALABAMA PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DENTAID DENTAL CENTER PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CRESTWOOD BLVD | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | IRONDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352102034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052716851 | ||||||||
| FaxNumber: | 2052716836 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366062162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514735705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2010 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2052716851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 4794 | AL | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.