MEDICARE: DR. GABRIEL ALPHONSE CHAMBLIN V DMD

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	122300000X	Dentist	3925	AL

General Provider Information

NPI Number	:	1083705594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL ALPHONSE CHAMBLIN V DMD

Provider Business Mailing Address
First Line	:	6450 US HIGHWAY 90
Second Line	:	SUITE D
City	:	SPANISH FORT
State	:	AL
Zip	:	36527-9405
Country	:	US
Telephone Number	:	251-626-7675
Fax Number	:	251-626-8194

Provider Business Practice Location Address
First Line	:	6450 US HIGHWAY 90
Second Line	:	SUITE D
City	:	SPANISH FORT
State	:	AL
Zip	:	36527-9405
Country	:	US
Telephone Number	:	251-626-7675
Fax Number	:	251-626-8194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	03/19/2008

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