Healthcare Provider Details

I. General information

NPI: 1255985289
Provider Name (Legal Business Name): ZACKERY ETHAN EADES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/05/2025
Certification Date: 07/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 STATION DR STE A
PRATTVILLE AL
36066-5671
US

IV. Provider business mailing address

1803 STATION DR STE A
PRATTVILLE AL
36066-5671
US

V. Phone/Fax

Practice location:
  • Phone: 334-361-9880
  • Fax:
Mailing address:
  • Phone: 334-361-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0006649-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: