Provider Demographics
NPI:1124565676
Name:DENTISTRY FOR AWESOME KIDS
Entity Type:Organization
Organization Name:DENTISTRY FOR AWESOME KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-447-0202
Mailing Address - Street 1:623 8TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35204-3604
Mailing Address - Country:US
Mailing Address - Phone:334-505-0891
Mailing Address - Fax:
Practice Address - Street 1:623 8TH AVE W
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35204-3604
Practice Address - Country:US
Practice Address - Phone:334-505-0891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1114368800Medicaid
AL1992970545Medicaid