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General NPI Number Information
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NPI Number | 1184935959
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Entity Type | Organization
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Legal Business Name | MADISON PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 06/27/2010
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Last Update Date | 04/15/2013
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Provider Practice Location Address
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Address Line | 7559 HIGHWAY 72 W SUITE C7/C8
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City | MADISON
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State | AL
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Zip | 35758-8811
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Country | US
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Telephone | 256-527-4590
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Fax | 256-890-4293
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Provider Business Mailing Address
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Address Line | 7559 HIGHWAY 72 W
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City | MADISON
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State | AL
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Zip | 35758-8811
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Country | US
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Telephone | 256-527-4590
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Fax | 256-890-4293
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Authorized Official
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Title or Position | MEMBER
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Name | DR. WESLEY MOFFETT
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Credential | D.M.D.
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Telephone | 205-792-0003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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