Provider Demographics
NPI:1245407436
Name:KNOLLWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:KNOLLWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:251-666-3982
Mailing Address - Street 1:5612 COTTAGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-4211
Mailing Address - Country:US
Mailing Address - Phone:251-666-3982
Mailing Address - Fax:
Practice Address - Street 1:5612 COTTAGE HILL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-4211
Practice Address - Country:US
Practice Address - Phone:251-666-3982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3028261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental