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General NPI Number Information
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NPI Number | 1093452633
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Entity Type | Organization
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Legal Business Name | 1917 DENTAL CLINIC
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Dates
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Enumeration Date | 05/16/2022
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 3220 5TH AVE S # 2022
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City | BIRMINGHAM
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State | AL
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Zip | 35222-2309
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Country | US
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Telephone | 205-975-9842
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Fax |
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Provider Business Mailing Address
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Address Line | 3220 5TH AVE S # 2022
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City | BIRMINGHAM
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State | AL
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Zip | 35222-2309
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Country | US
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Telephone | 205-975-9842
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Fax |
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Authorized Official
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Title or Position | BUSINESS OFFICE DIRECTOR
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Name | JACQUISELYN STORY
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Credential |
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Telephone | 205-934-5088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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