Basic Information
| Provider Information | |||||||||
| NPI: | 1700178654 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITAL SMILES ALABAMA, P. C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 CENTER POINT PKWY | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352152548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058548093 | ||||||||
| FaxNumber: | 2058548095 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 CENTER POINT PKWY | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352152548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052716851 | ||||||||
| FaxNumber: | 2052716836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2052716851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D. D. S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | AL3061 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.