Healthcare Provider Details

I. General information

NPI: 1053571364
Provider Name (Legal Business Name): AZALEA CITY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 N CRAFT HWY
CHICKASAW AL
36611-1364
US

IV. Provider business mailing address

457 N CRAFT HWY
CHICKASAW AL
36611-1364
US

V. Phone/Fax

Practice location:
  • Phone: 251-456-8406
  • Fax: 251-456-8108
Mailing address:
  • Phone: 251-456-8406
  • Fax: 251-456-8108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CINDY BLACK
Title or Position: OFFICE MANAGER
Credential:
Phone: 251-456-8406