Provider Demographics
NPI:1235471426
Name:AUTAUGA STATION DENTAL, P.C.
Entity Type:Organization
Organization Name:AUTAUGA STATION DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:C
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-361-9880
Mailing Address - Street 1:1803 STATION DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5668
Mailing Address - Country:US
Mailing Address - Phone:334-361-9880
Mailing Address - Fax:334-361-9876
Practice Address - Street 1:1803 STATION DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5668
Practice Address - Country:US
Practice Address - Phone:334-361-9880
Practice Address - Fax:334-361-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL49491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty