Provider Demographics
NPI:1275806770
Name:AZALEA CITY DENTAL LLC
Entity Type:Organization
Organization Name:AZALEA CITY DENTAL LLC
Other - Org Name:AZALEA CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-300-6100
Mailing Address - Street 1:6593 SPANISH FORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-5015
Mailing Address - Country:US
Mailing Address - Phone:251-300-6100
Mailing Address - Fax:
Practice Address - Street 1:6593 SPANISH FORT BLVD
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-5015
Practice Address - Country:US
Practice Address - Phone:251-300-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty