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General NPI Number Information
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NPI Number | 1235435785
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Entity Type | Organization
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Legal Business Name | FAIRHOPE COSMETIC DENTISTRY AND FRESH BEATH CENTER
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 05/07/2015
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Provider Practice Location Address
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Address Line | 101 FLY CREEK AVENUE SUITE 301
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City | FAIRHOPE
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State | AL
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Zip | 36532
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Country | US
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Telephone | 251-990-7797
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Fax | 251-990-7769
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Provider Business Mailing Address
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Address Line | 7540 CIPRIANO CT
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City | FAIRHOPE
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State | AL
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Zip | 36532-3029
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Country | US
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Telephone | 251-990-7797
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAMES M. CLARK
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Credential | D.M.D.
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Telephone | 251-990-7797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | AL3834
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License Number State | AL
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