Healthcare Provider Details

I. General information

NPI: 1366367385
Provider Name (Legal Business Name): JASPER DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 THE MALL WAY
JASPER AL
35504-7514
US

IV. Provider business mailing address

310 THE MALL WAY
JASPER AL
35504-7514
US

V. Phone/Fax

Practice location:
  • Phone: 205-221-5610
  • Fax:
Mailing address:
  • Phone: 205-221-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHAD HENDRICKS
Title or Position: CREDENTIALING
Credential:
Phone: 612-859-0444