Healthcare Provider Details

I. General information

NPI: 1841046703
Provider Name (Legal Business Name): PDA OF TRUSSVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 CAMP COLEMAN RD STE 101
TRUSSVILLE AL
35173-2838
US

IV. Provider business mailing address

50 CROPWELL DR STE 2
PELL CITY AL
35128-7552
US

V. Phone/Fax

Practice location:
  • Phone: 678-628-8303
  • Fax: 256-285-1485
Mailing address:
  • Phone: 678-628-8303
  • Fax: 256-285-1485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RICHARD BAKER CHAMBLISS
Title or Position: OWNER
Credential: DMD
Phone: 205-453-0314