Provider Demographics
NPI:1073608477
Name:DECATUR FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:DECATUR FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:NAILS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-355-1557
Mailing Address - Street 1:2426 DANVILLE ROAD SW
Mailing Address - Street 2:SUITE R
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603
Mailing Address - Country:US
Mailing Address - Phone:256-355-1557
Mailing Address - Fax:256-355-1911
Practice Address - Street 1:2426 DANVILLE ROAD SW
Practice Address - Street 2:SUITE R
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603
Practice Address - Country:US
Practice Address - Phone:256-355-1557
Practice Address - Fax:256-355-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1375438OtherUNITED CONCORDIA PROV. #
AL51507837NAIOtherBCBS OF AL PROV. #