Provider Demographics
NPI:1013558766
Name:SOUTHERN SMILES
Entity Type:Organization
Organization Name:SOUTHERN SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:GRAVES
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-988-5858
Mailing Address - Street 1:2801 JOHN HAWKINS PKWY STE 175
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4007
Mailing Address - Country:US
Mailing Address - Phone:205-988-5858
Mailing Address - Fax:205-988-5886
Practice Address - Street 1:2801 JOHN HAWKINS PKWY STE 175
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4007
Practice Address - Country:US
Practice Address - Phone:205-988-5858
Practice Address - Fax:205-988-5886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639579626OtherGENERAL
FL1639579626Medicaid