Healthcare Provider Details

I. General information

NPI: 1255439964
Provider Name (Legal Business Name): BIRMINGHAM ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 INVERNESS CENTER DR SUITE 202
BIRMINGHAM AL
35242-7635
US

IV. Provider business mailing address

202 INVERNESS CENTER DRIVE SUITE 202
BIRMINGHAM AL
35242-7635
US

V. Phone/Fax

Practice location:
  • Phone: 205-981-3301
  • Fax: 205-981-3307
Mailing address:
  • Phone: 205-981-3301
  • Fax: 205-981-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISSIE BAKER AYCOCK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 205-981-3301