=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003207796
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRECIOUS SMILES FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2015
-----------------------------------------------------
Last Update Date | 02/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 BALCH RD SUITE 100
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35758-8343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-434-5179
-----------------------------------------------------
Fax | 256-467-8068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1041 BALCH RD SUITE 100
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35758-8343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-434-5179
-----------------------------------------------------
Fax | 256-467-8068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. PRECIOUS MONTEY MCGREGOR-WILTZ
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 504-444-5236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5908
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------