Provider Demographics
NPI:1043351950
Name:NORTH JEFFERSON PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:NORTH JEFFERSON PEDIATRIC DENTISTRY, LLC
Other - Org Name:AMY T. PARVIN, D.M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-631-2240
Mailing Address - Street 1:925 SHARIT AVE
Mailing Address - Street 2:STUITE 113
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-5000
Mailing Address - Country:US
Mailing Address - Phone:205-631-2240
Mailing Address - Fax:205-631-1611
Practice Address - Street 1:925 SHARIT AVE
Practice Address - Street 2:STUITE 113
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-5000
Practice Address - Country:US
Practice Address - Phone:205-631-2240
Practice Address - Fax:205-631-1611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL49701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1356891OtherUCCI
AL51531288OtherBCBS OF ALABAMA