Healthcare Provider Details

I. General information

NPI: 1265612469
Provider Name (Legal Business Name): PEDIATRIC DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S 5TH ST
GADSDEN AL
35901-5102
US

IV. Provider business mailing address

404 S 5TH ST
GADSDEN AL
35901-5102
US

V. Phone/Fax

Practice location:
  • Phone: 256-546-4604
  • Fax: 256-546-4674
Mailing address:
  • Phone: 256-546-4604
  • Fax: 256-546-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateAL

VIII. Authorized Official

Name: DR. MICHAEL A HOLMES SR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 256-546-4604