Healthcare Provider Details

I. General information

NPI: 1922961341
Provider Name (Legal Business Name): EASTERN SHORE DENTAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 US HIGHWAY 98
DAPHNE AL
36526-4365
US

IV. Provider business mailing address

2213 US HIGHWAY 98
DAPHNE AL
36526-4365
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-0620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: JOHN GREEN JR.
Title or Position: OWNER
Credential:
Phone: 251-928-0620