Healthcare Provider Details

I. General information

NPI: 1861052813
Provider Name (Legal Business Name): KLYNE CHANNING FAWCETT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2138 HELTON DR
FLORENCE AL
35630-1449
US

IV. Provider business mailing address

2138 HELTON DR
FLORENCE AL
35630-1449
US

V. Phone/Fax

Practice location:
  • Phone: 256-766-5112
  • Fax: 256-760-1063
Mailing address:
  • Phone: 256-766-5112
  • Fax: 256-760-1063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number6664
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: