=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700115201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2009
-----------------------------------------------------
Last Update Date | 12/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 W ELM ST
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35611-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-262-0200
-----------------------------------------------------
Fax | 256-262-0201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3322 W END AVE STE 400
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-6805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 629-999-5014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER, LICENSING & CREDENTIALING
-----------------------------------------------------
Name | SHERRIE EDMONDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 629-999-5014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------