Healthcare Provider Details

I. General information

NPI: 1346583457
Provider Name (Legal Business Name): SOUTHSIDE FAMILY & COSMETIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 HIGHWAY 77
SOUTHSIDE AL
35907-0169
US

IV. Provider business mailing address

1745 HIGHWAY 77
SOUTHSIDE AL
35907-0169
US

V. Phone/Fax

Practice location:
  • Phone: 256-442-1463
  • Fax: 256-442-9821
Mailing address:
  • Phone: 256-442-1463
  • Fax: 256-442-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DONNA JENNINGS
Title or Position: OFFICE MANAGER
Credential:
Phone: 256-442-1463