Healthcare Provider Details

I. General information

NPI: 1851697643
Provider Name (Legal Business Name): ALABAMA DENTAL PROFESSIONALS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 S BROAD ST
SCOTTSBORO AL
35768-2512
US

IV. Provider business mailing address

1202 S BROAD ST
SCOTTSBORO AL
35768-2512
US

V. Phone/Fax

Practice location:
  • Phone: 256-259-5955
  • Fax: 256-259-5954
Mailing address:
  • Phone: 256-259-5955
  • Fax: 256-259-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4762
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number4762
License Number StateAL

VIII. Authorized Official

Name: KIM ZUBER
Title or Position: CRED SUP
Credential:
Phone: 217-540-5170