=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649924887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STONECREEK DENTAL OF ALABAMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2022
-----------------------------------------------------
Last Update Date | 02/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2074 VALLEYDALE RD
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-991-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2074 VALLEYDALE RD
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE MANAGER
-----------------------------------------------------
Name | VERONICA JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-191-7509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------