MEDICARE: AZALEA CITY DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1053571364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZALEA CITY DENTAL, LLC

Provider Business Mailing Address
First Line	:	457 N CRAFT HWY
Second Line	:
City	:	CHICKASAW
State	:	AL
Zip	:	36611-1364
Country	:	US
Telephone Number	:	251-456-8406
Fax Number	:	251-456-8108

Provider Business Practice Location Address
First Line	:	457 N CRAFT HWY
Second Line	:
City	:	CHICKASAW
State	:	AL
Zip	:	36611-1364
Country	:	US
Telephone Number	:	251-456-8406
Fax Number	:	251-456-8108

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CINDY BLACK
Credential	:
Telephone Number	:	251-456-8406

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	06/10/2008

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Directions to “AZALEA CITY DENTAL, LLC ” Practice Location

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