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General NPI Number Information
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NPI Number | 1134392517
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Entity Type | Organization
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Legal Business Name | FRESH WAVE DENTAL CARE
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Dates
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Enumeration Date | 04/08/2008
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Last Update Date | 04/08/2008
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Provider Practice Location Address
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Address Line | 812 BOLL WEEVIL CIR
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City | ENTERPRISE
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State | AL
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Zip | 36330-2079
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Country | US
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Telephone | 334-347-9283
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Fax |
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Provider Business Mailing Address
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Address Line | 812 BOLL WEEVIL CIR
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City | ENTERPRISE
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State | AL
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Zip | 36330-2079
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Country | US
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Telephone | 334-347-9283
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Fax |
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Authorized Official
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Title or Position | OFFICE MANGER
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Name | MRS. DEBBIELEE J HAWN
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Credential |
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Telephone | 334-347-9283
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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 | 4810
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License Number State | AL
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