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General NPI Number Information
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NPI Number | 1467025866
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Entity Type | Organization
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Legal Business Name | PDA ORTHO CULLMAN LLC
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Dates
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Enumeration Date | 07/22/2021
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 1907 MAIN AVE SW STE A
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City | CULLMAN
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State | AL
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Zip | 35055-5218
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Country | US
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Telephone | 256-279-9852
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Fax |
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Provider Business Mailing Address
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Address Line | 5564 GROVE BLVD STE A
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City | HOOVER
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State | AL
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Zip | 35226-4601
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | MALLORY SAMUELSON
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Credential |
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Telephone | 615-631-9226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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