Provider Demographics
NPI:1093452633
Name:1917 DENTAL CLINIC
Entity Type:Organization
Organization Name:1917 DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUISELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-934-5088
Mailing Address - Street 1:3220 5TH AVE S # 2022
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-2309
Mailing Address - Country:US
Mailing Address - Phone:205-975-9842
Mailing Address - Fax:
Practice Address - Street 1:3220 5TH AVE S # 2022
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35222-2309
Practice Address - Country:US
Practice Address - Phone:205-975-9842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ALABAMA AT BIRMINGHAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-16
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty