Healthcare Provider Details

I. General information

NPI: 1902297690
Provider Name (Legal Business Name): AESTHETIC AND RECONSTRUCTIVE DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 BALCH RD SUITE 180
MADISON AL
35758-8343
US

IV. Provider business mailing address

1041 BALCH RD SUITE 180
MADISON AL
35758-8343
US

V. Phone/Fax

Practice location:
  • Phone: 256-319-3256
  • Fax: 256-319-3257
Mailing address:
  • Phone: 256-319-3256
  • Fax: 256-319-3257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5928
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number233720-00
License Number StateAL

VIII. Authorized Official

Name: DR. CRAMIN PETER WILTZ II
Title or Position: SOLE MEMBER
Credential: DMD, CDT
Phone: 256-319-3256