Provider Demographics
NPI:1043231293
Name:FAIRHOPE DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:FAIRHOPE DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:251-928-0620
Mailing Address - Street 1:108 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-1922
Mailing Address - Country:US
Mailing Address - Phone:251-928-0620
Mailing Address - Fax:251-928-1359
Practice Address - Street 1:108 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1922
Practice Address - Country:US
Practice Address - Phone:251-928-0620
Practice Address - Fax:251-928-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1906760OtherUNITED CONCORDIA
AL03142OtherBCBS