Provider Demographics
NPI:1336314160
Name:S.M. MAHAN L.L.C
Entity Type:Organization
Organization Name:S.M. MAHAN L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-665-2723
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:BRIERFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35035-0100
Mailing Address - Country:US
Mailing Address - Phone:205-665-2723
Mailing Address - Fax:205-665-1037
Practice Address - Street 1:19330 HIGHWAY 139
Practice Address - Street 2:
Practice Address - City:BRIERFIELD
Practice Address - State:AL
Practice Address - Zip Code:35035-3658
Practice Address - Country:US
Practice Address - Phone:205-665-2723
Practice Address - Fax:205-665-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529919020Medicaid