Provider Demographics
NPI:1073977211
Name:GENESIS DENTAL GROUP FOLEY PC
Entity Type:Organization
Organization Name:GENESIS DENTAL GROUP FOLEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-281-2451
Mailing Address - Street 1:3150 ZELDA CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2607
Mailing Address - Country:US
Mailing Address - Phone:334-281-2451
Mailing Address - Fax:334-281-1087
Practice Address - Street 1:100 ELECIA LN
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-8970
Practice Address - Country:US
Practice Address - Phone:251-943-5088
Practice Address - Fax:251-970-1611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty