MEDICARE: VITAL SMILES ALABAMA II PC

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

General Provider Information

NPI Number	:	1265999395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL SMILES ALABAMA II PC

Provider Business Mailing Address
First Line	:	530 S MAIN ST
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4525
Country	:	US
Telephone Number	:	714-480-3000
Fax Number	:	714-571-6445

Provider Business Practice Location Address
First Line	:	3700 BLUE SPRING RD NW STE F
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35810-3457
Country	:	US
Telephone Number	:	256-852-9994
Fax Number	:	256-852-7797

Authorized Official
Title or Position	:	CHIEF INFORMATION OFFICER
Name	:	PREET TAKKAR
Credential	:
Telephone Number	:	714-571-3372

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	02/25/2019

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