=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053652347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7900 BAILEY COVE RD SE STE 6
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35802-3341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-883-6318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16242 TRAVERTINE DR
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35613-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BARRY SCOTT FITTS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 256-230-5174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5493
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------