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General NPI Number Information
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NPI Number | 1265970487
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Entity Type | Organization
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Legal Business Name | PAUL GASTON PETZNICK DMD FAGD LLC
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Dates
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Enumeration Date | 02/08/2017
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 2045 BROOKWOOD MEDICAL CTR DR SUITE 6
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City | HOMEWOOD
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State | AL
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Zip | 35209-6874
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Country | US
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Telephone | 205-326-7444
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Fax | 205-637-1933
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Provider Business Mailing Address
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Address Line | PO BOX 530652
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City | BIRMINGHAM
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State | AL
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Zip | 35253-0652
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Country | US
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Telephone | 205-326-7444
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Fax | 205-637-1933
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Authorized Official
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Title or Position | DENTIST
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Name | DR. PAUL GASTON PETZNICK
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Credential | DMD
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Telephone | 205-326-7444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4316
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License Number State | AL
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