Healthcare Provider Details

I. General information

NPI: 1518127828
Provider Name (Legal Business Name): AZALEA CITY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1754 GOVERNMENT ST
MOBILE AL
36604-1111
US

IV. Provider business mailing address

1754 GOVERNMENT ST
MOBILE AL
36604-1111
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-1516
  • Fax: 251-471-8002
Mailing address:
  • Phone: 251-471-1516
  • Fax: 251-471-8002

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: MS. TRACY WOODALL
Title or Position: OFFICE MANAGER
Credential:
Phone: 251-471-1516