Healthcare Provider Details

I. General information

NPI: 1134292196
Provider Name (Legal Business Name): KEITH WOODALL DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 NORTH 20TH STREET 20A
OPELIKA AL
36801
US

IV. Provider business mailing address

121 NORTH 20TH STREET 20A
OPELIKA AL
36801
US

V. Phone/Fax

Practice location:
  • Phone: 334-749-1268
  • Fax: 334-745-4221
Mailing address:
  • Phone: 334-749-1268
  • Fax: 334-745-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2832
License Number StateAL

VIII. Authorized Official

Name: PAUL KEITH WOODALL SR.
Title or Position: ORTHODONTIST PRESIDENT
Credential: DMD
Phone: 334-749-1268