=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851751986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TICKLE FAMILY AND IMPLANT DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2016
-----------------------------------------------------
Last Update Date | 03/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 HARGROVE RD E SUITE B
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-3792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-758-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 HARGROVE RD E SUITE B
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-3792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-758-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK TICKLE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 205-758-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5706
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------