Provider Demographics
NPI:1356002166
Name:STONECREEK DENTAL OF ALABAMA
Entity Type:Organization
Organization Name:STONECREEK DENTAL OF ALABAMA
Other - Org Name:DIAMOND SMILES HOOVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-538-5464
Mailing Address - Street 1:5336 STADIUM TRACE PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4581
Mailing Address - Country:US
Mailing Address - Phone:205-988-9700
Mailing Address - Fax:
Practice Address - Street 1:5336 STADIUM TRACE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4581
Practice Address - Country:US
Practice Address - Phone:205-988-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONECREEK DENTAL OF ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-04
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0000OtherNONE