Provider Demographics
NPI:1326232364
Name:PEDIATRIC DENTISTRY EAST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:NIMER
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-655-1000
Mailing Address - Street 1:123 N CHALKVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1376
Mailing Address - Country:US
Mailing Address - Phone:205-655-1000
Mailing Address - Fax:205-228-8044
Practice Address - Street 1:123 N CHALKVILLE RD
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1376
Practice Address - Country:US
Practice Address - Phone:205-655-1000
Practice Address - Fax:205-228-8044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL46551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty