MEDICARE: MEDPLEX PEDIATRIC DENTISTRY, INC.

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	5181	AL

General Provider Information

NPI Number	:	1518078674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDPLEX PEDIATRIC DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	4515 SOUTHLAKE PKWY
Second Line	:	SUITE 200
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-3317
Country	:	US
Telephone Number	:	205-453-0314
Fax Number	:	205-453-0315

Provider Business Practice Location Address
First Line	:	4515 SOUTHLAKE PKWY
Second Line	:	SUITE 200
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-3317
Country	:	US
Telephone Number	:	205-453-0314
Fax Number	:	205-453-0315

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD BAKER CHAMBLISS JR.
Credential	:	DMD
Telephone Number	:	205-453-0314

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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