Provider Demographics
NPI:1114392107
Name:TOOTH BUDS AT LAGOON PARK, LLC
Entity Type:Organization
Organization Name:TOOTH BUDS AT LAGOON PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-801-9800
Mailing Address - Street 1:553 N EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-2213
Mailing Address - Country:US
Mailing Address - Phone:334-801-9800
Mailing Address - Fax:334-801-9848
Practice Address - Street 1:553 N EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2213
Practice Address - Country:US
Practice Address - Phone:334-801-9800
Practice Address - Fax:334-801-9848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty