Provider Demographics
NPI:1396406864
Name:STONECREEK DENTAL OF ALABAMA
Entity Type:Organization
Organization Name:STONECREEK DENTAL OF ALABAMA
Other - Org Name:
Other - Org Type:
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 1:112 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5312
Mailing Address - Country:US
Mailing Address - Phone:205-847-1415
Mailing Address - Fax:
Practice Address - Street 1:112 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-5312
Practice Address - Country:US
Practice Address - Phone:205-847-1415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONECREEK DENTAL OF ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherNONE