Healthcare Provider Details

I. General information

NPI: 1134421746
Provider Name (Legal Business Name): VITAL SMILES ALABAMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 PLEASANT VALLEY RD
MOBILE AL
36606-2162
US

IV. Provider business mailing address

1900 CRESTWOOD BLVD SUITE 211
IRONDALE AL
35210-2034
US

V. Phone/Fax

Practice location:
  • Phone: 251-473-5705
  • Fax:
Mailing address:
  • Phone: 205-271-6851
  • Fax: 205-271-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number4794
License Number StateAL

VIII. Authorized Official

Name: DR. GEORGE DAVID JOHNSON JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 205-271-6851