Provider Demographics
NPI:1427418441
Name:ASHVILLE FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:ASHVILLE FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-594-5044
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35953-0129
Mailing Address - Country:US
Mailing Address - Phone:205-594-5044
Mailing Address - Fax:
Practice Address - Street 1:279 5TH AVE
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:AL
Practice Address - Zip Code:35953-3339
Practice Address - Country:US
Practice Address - Phone:205-594-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5192261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009955935Medicaid