MEDICARE: VITAL SMILES 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	AL3061	AL

General Provider Information

NPI Number	:	1700178654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL SMILES ALABAMA, P. C.

Provider Business Mailing Address
First Line	:	2525 CENTER POINT PKWY
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35215-2548
Country	:	US
Telephone Number	:	205-854-8093
Fax Number	:	205-854-8095

Provider Business Practice Location Address
First Line	:	2525 CENTER POINT PKWY
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35215-2548
Country	:	US
Telephone Number	:	205-271-6851
Fax Number	:	205-271-6836

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GEORGE DAVID JOHNSON
Credential	:	D. D. S.
Telephone Number	:	205-271-6851

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	12/07/2011

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