Healthcare Provider Details

I. General information

NPI: 1083705594
Provider Name (Legal Business Name): GABRIEL ALPHONSE CHAMBLIN V DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 US HIGHWAY 90 SUITE D
SPANISH FORT AL
36527-9405
US

IV. Provider business mailing address

6450 US HIGHWAY 90 SUITE D
SPANISH FORT AL
36527-9405
US

V. Phone/Fax

Practice location:
  • Phone: 251-626-7675
  • Fax: 251-626-8194
Mailing address:
  • Phone: 251-626-7675
  • Fax: 251-626-8194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3925
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: