Provider Demographics
NPI:1245407154
Name:PROSTHODONTICS DENTAL LABORATORY, INC.
Entity Type:Organization
Organization Name:PROSTHODONTICS DENTAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-880-7414
Mailing Address - Street 1:2227 DRAKE AVE SW
Mailing Address - Street 2:SUITE 10E
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-5199
Mailing Address - Country:US
Mailing Address - Phone:256-880-7414
Mailing Address - Fax:
Practice Address - Street 1:2227 DRAKE AVE SW
Practice Address - Street 2:SUITE 10E
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-5199
Practice Address - Country:US
Practice Address - Phone:256-880-7414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL001448292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory