Healthcare Provider Details

I. General information

NPI: 1043815590
Provider Name (Legal Business Name): PDA ORTHODONTICS TRUSSVILLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 DEERFOOT PKWY STE 101
TRUSSVILLE AL
35173-2697
US

IV. Provider business mailing address

5336 STADIUM TRACE PKWY STE 112
HOOVER AL
35244-4581
US

V. Phone/Fax

Practice location:
  • Phone: 205-508-7135
  • Fax:
Mailing address:
  • Phone: 205-988-9678
  • Fax: 205-988-9065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN EARL SAMUELSON
Title or Position: OWNER/ORTHODONTIST
Credential: DMD, MS
Phone: 205-910-0143