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General NPI Number Information
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NPI Number | 1972863348
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Entity Type | Organization
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Legal Business Name | GENEVA FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 05/20/2012
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Last Update Date | 05/20/2012
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Provider Practice Location Address
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Address Line | 100 W LAKE PROFESSIONAL PARK SUITE 5
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City | GENEVA
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State | AL
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Zip | 36340-1203
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Country | US
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Telephone | 334-805-3975
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Fax |
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Provider Business Mailing Address
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Address Line | 100 W LAKE PROFESSIONAL PARK SUITE 5
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City | GENEVA
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State | AL
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Zip | 36340-1203
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Country | US
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Telephone | 334-805-3975
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER-OWNER
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Name | JONATHAN DAVID MARKHAM
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Credential | DMD
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Telephone | 334-805-3975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5826
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License Number State | AL
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