Healthcare Provider Details

I. General information

NPI: 1013249242
Provider Name (Legal Business Name): ALABAMA DENTAL PROFESSIONALS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2010
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COLLEGE ST. SUITE D
ATHENS AL
35611
US

IV. Provider business mailing address

110 COLLEGE ST. SUITE D
ATHENS AL
35611
US

V. Phone/Fax

Practice location:
  • Phone: 256-232-0789
  • Fax: 256-232-5247
Mailing address:
  • Phone: 256-232-0789
  • Fax: 256-232-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3836
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5267
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4084
License Number StateAL

VIII. Authorized Official

Name: MRS. KENDRA WALKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8312