Healthcare Provider Details

I. General information

NPI: 1336518331
Provider Name (Legal Business Name): SEA SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2015
Last Update Date: 09/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N ALSTON ST
FOLEY AL
36535-3509
US

IV. Provider business mailing address

825 N ALSTON ST
FOLEY AL
36535-3509
US

V. Phone/Fax

Practice location:
  • Phone: 251-943-7575
  • Fax:
Mailing address:
  • Phone: 251-943-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5789
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5811
License Number StateAL

VIII. Authorized Official

Name: DR. MICHAEL O'NEILL MEADOR JR.
Title or Position: DENTIST
Credential: DMD
Phone: 850-712-5024