Healthcare Provider Details

I. General information

NPI: 1801077334
Provider Name (Legal Business Name): TRUSSVILLE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N CHALKVILLE RD STE 1
TRUSSVILLE AL
35173-1376
US

IV. Provider business mailing address

123 N CHALKVILLE RD STE 1
TRUSSVILLE AL
35173-1376
US

V. Phone/Fax

Practice location:
  • Phone: 205-655-1000
  • Fax: 205-655-7196
Mailing address:
  • Phone: 205-655-1000
  • Fax: 205-655-7196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5379
License Number StateAL

VIII. Authorized Official

Name: DR. THOMAS G WILLINGHAM
Title or Position: OWNER
Credential: DMD
Phone: 205-655-1000