Basic Information
| Provider Information | |||||||||
| NPI: | 1740335934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VITAL SMILES ALABAMA, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE TOOTH ZONE II, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CRESTWOOD BLVD | ||||||||
| Address2: | STE 211 | ||||||||
| City: | IRONDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352102034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052716851 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 B Y WILLIAMS SR DR | ||||||||
| Address2: | |||||||||
| City: | MIDFIELD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352282218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059233172 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2052716851 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.