Healthcare Provider Details

I. General information

NPI: 1730070665
Provider Name (Legal Business Name): MINA OH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 CARMICHAEL RD
MONTGOMERY AL
36106-3600
US

IV. Provider business mailing address

1010 BEACON PKWY E UNIT 1121
BIRMINGHAM AL
35209-3206
US

V. Phone/Fax

Practice location:
  • Phone: 334-277-2980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD.007452-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: