Healthcare Provider Details

I. General information

NPI: 1114186699
Provider Name (Legal Business Name): ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 RUCKER BLVD STE A-1
ENTERPRISE AL
36330-3623
US

IV. Provider business mailing address

PO BOX 411714
BOSTON MA
02241-6805
US

V. Phone/Fax

Practice location:
  • Phone: 334-347-5550
  • Fax: 334-347-5551
Mailing address:
  • Phone: 629-999-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateAL

VIII. Authorized Official

Name: SHERRIE EDMONDSON
Title or Position: SR MANAGER, L& C
Credential:
Phone: 629-999-5014