Healthcare Provider Details

I. General information

NPI: 1255740122
Provider Name (Legal Business Name): MOBILE BAY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 SCHILLINGER RD N
SEMMES AL
36575-7409
US

IV. Provider business mailing address

1651 SCHILLINGER RD N
SEMMES AL
36575-7409
US

V. Phone/Fax

Practice location:
  • Phone: 251-706-7960
  • Fax:
Mailing address:
  • Phone: 251-706-7960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5226
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-779-TA-178
License Number StateAL

VIII. Authorized Official

Name: LANCE HANKINSON
Title or Position: OWNER
Credential: DMD
Phone: 251-706-7960