Provider Demographics
NPI:1194030387
Name:ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.
Entity Type:Organization
Organization Name:ADVANTAGE DENTAL ORAL HEALTH AND VISION CENTER OF ALABAMA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-999-5014
Mailing Address - Street 1:PO BOX 411714
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6805
Mailing Address - Country:US
Mailing Address - Phone:629-999-5014
Mailing Address - Fax:
Practice Address - Street 1:1141 JASPER DENNIS RD
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-3783
Practice Address - Country:US
Practice Address - Phone:205-312-0001
Practice Address - Fax:205-312-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL121795Medicaid