Healthcare Provider Details

I. General information

NPI: 1194216861
Provider Name (Legal Business Name): SHOAL CREEK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 HIGHWAY 72
KILLEN AL
35645-9136
US

IV. Provider business mailing address

1303 HIGHWAY 72
KILLEN AL
35645-9136
US

V. Phone/Fax

Practice location:
  • Phone: 256-757-5314
  • Fax:
Mailing address:
  • Phone: 256-757-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3415
License Number StateAL

VIII. Authorized Official

Name: BRUCE EVANS
Title or Position: OWNER
Credential: D.M.D.
Phone: 256-766-8800