Provider Demographics
NPI:1144588906
Name:PINE BELT DENTAL LLC
Entity Type:Organization
Organization Name:PINE BELT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-275-3822
Mailing Address - Street 1:297C S JACKSON ST
Mailing Address - Street 2:P O BOX 129
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-3231
Mailing Address - Country:US
Mailing Address - Phone:251-275-3822
Mailing Address - Fax:251-275-4190
Practice Address - Street 1:297C S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-3822
Practice Address - Fax:251-275-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL32871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1962737916OtherNATIONAL PROVIDER IDENTIFIER
AL1558445999OtherNATIONAL PROVIDER IDENTIFIER