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General NPI Number Information
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NPI Number | 1053571364
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Entity Type | Organization
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Legal Business Name | AZALEA CITY DENTAL, LLC
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Dates
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Enumeration Date | 06/10/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 457 N CRAFT HWY
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City | CHICKASAW
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State | AL
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Zip | 36611-1364
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Country | US
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Telephone | 251-456-8406
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Fax | 251-456-8108
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Provider Business Mailing Address
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Address Line | 457 N CRAFT HWY
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City | CHICKASAW
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State | AL
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Zip | 36611-1364
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Country | US
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Telephone | 251-456-8406
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Fax | 251-456-8108
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CINDY BLACK
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Credential |
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Telephone | 251-456-8406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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