MEDICARE: ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.

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	1223P0221X	Pediatric Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225403397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.

Provider Business Mailing Address
First Line	:	230 E 10TH ST
Second Line	:	SUITE 106
City	:	ANNISTON
State	:	AL
Zip	:	36207-5771
Country	:	US
Telephone Number	:	256-741-7340
Fax Number	:	256-741-7373

Provider Business Practice Location Address
First Line	:	1810 STADIUM DR
Second Line	:	SUITE 120
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-3177
Country	:	US
Telephone Number	:	334-480-4004
Fax Number	:	334-480-4040

Authorized Official
Title or Position	:	MANAGER, LICENSING & CREDENTIALING
Name	:	SHERRIE EDMONDSON
Credential	:
Telephone Number	:	629-999-5014

Provider Enumeration Date	:	12/01/2015
Last Update Date	:	12/30/2021

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