Healthcare Provider Details

I. General information

NPI: 1063969368
Provider Name (Legal Business Name): CHILDREN AND TEEN ORTHO GROUP OF ALABAMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 RICE MINE RD NE STE 260
TUSCALOOSA AL
35406-2401
US

IV. Provider business mailing address

342 N MAIN ST STE 200
ALPHARETTA GA
30009-8376
US

V. Phone/Fax

Practice location:
  • Phone: 205-758-3341
  • Fax: 678-550-5490
Mailing address:
  • Phone: 205-758-3341
  • Fax: 205-366-1099

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: CRYSTAL WALKER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 770-744-4522