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General NPI Number Information
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NPI Number | 1336973999
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Entity Type | Organization
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Legal Business Name | SOUTHERN ROOTS FAMILY AND COSMETIC DENTISTRY
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Dates
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Enumeration Date | 08/27/2024
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Last Update Date | 09/18/2024
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Provider Practice Location Address
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Address Line | 6154 OMNI PARK DR
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City | MOBILE
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State | AL
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Zip | 36609-5195
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Country | US
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Telephone | 251-414-5142
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Fax |
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Provider Business Mailing Address
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Address Line | 6154 OMNI PARK DR
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City | MOBILE
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State | AL
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Zip | 36609-5195
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Country | US
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Telephone | 251-414-5142
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. WALTER P VICKERS JR.
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Credential |
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Telephone | 251-342-0380
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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 |
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License Number State |
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