=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134705478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEBELES ENDODONTICS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2021
-----------------------------------------------------
Last Update Date | 03/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4647 HIGHWAY 280 STE E
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-980-8777
-----------------------------------------------------
Fax | 205-408-2965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4647 HIGHWAY 280 STE E
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 120-598-0877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LISA R COOKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-980-8777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------