Healthcare Provider Details

I. General information

NPI: 1245135581
Provider Name (Legal Business Name): GRACE CHILDREN'S DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 RESEARCH LN
DOTHAN AL
36305-0001
US

IV. Provider business mailing address

2425 MEDICAL CENTER PKWY
SELMA AL
36701-7756
US

V. Phone/Fax

Practice location:
  • Phone: 334-875-1330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELIZABETH CULPEPPER
Title or Position: LICENSING
Credential:
Phone: 334-875-1330