Healthcare Provider Details

I. General information

NPI: 1770229023
Provider Name (Legal Business Name): SOUTH BALDWIN DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N CEDAR ST
FOLEY AL
36535-1478
US

IV. Provider business mailing address

101 N CEDAR ST
FOLEY AL
36535-1478
US

V. Phone/Fax

Practice location:
  • Phone: 125-194-3152
  • Fax:
Mailing address:
  • Phone: 125-194-3152
  • 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 State

VIII. Authorized Official

Name: EMMY ABERCROMBIE
Title or Position: OFFICE MANAGER
Credential:
Phone: 251-943-1521