Healthcare Provider Details

I. General information

NPI: 1124606447
Provider Name (Legal Business Name): ALLY PRITCHETT MIZERANY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 MCFARLAND CIR N
TUSCALOOSA AL
35406-1800
US

IV. Provider business mailing address

236 RALEIGH AVE
BIRMINGHAM AL
35209-6549
US

V. Phone/Fax

Practice location:
  • Phone: 205-345-7755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-0006919-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: