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General NPI Number Information
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NPI Number | 1619193216
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Entity Type | Organization
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Legal Business Name | GOOD HOPE DENTAL CENTER PC
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 203 COMMERCE CIR SW STE B
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City | DECATUR
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State | AL
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Zip | 35601-6840
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Country | US
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Telephone | 256-350-8182
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Fax | 256-350-3232
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Provider Business Mailing Address
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Address Line | 203 COMMERCE CIR SW STE B
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City | DECATUR
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State | AL
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Zip | 35601-6840
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Country | US
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Telephone | 256-350-8182
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Fax | 256-350-3232
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEON MALCOLM CLARK JR.
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Credential | D.M.D.
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Telephone | 256-350-8182
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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 | 4499
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License Number State | AL
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