Provider Demographics
NPI:1215024690
Name:CORNERSTONE DENTISTRY OF DECATUR
Entity Type:Organization
Organization Name:CORNERSTONE DENTISTRY OF DECATUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-353-1481
Mailing Address - Street 1:1215 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4306
Mailing Address - Country:US
Mailing Address - Phone:256-353-1481
Mailing Address - Fax:
Practice Address - Street 1:1215 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4306
Practice Address - Country:US
Practice Address - Phone:256-353-1481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL49651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty