Provider Demographics
NPI:1437289303
Name:SOUTH ALABAMA PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:SOUTH ALABAMA PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:GAINES
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-345-1717
Mailing Address - Street 1:801 UNIVERSITY BLVD S
Mailing Address - Street 2:STE B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-2923
Mailing Address - Country:US
Mailing Address - Phone:251-345-1717
Mailing Address - Fax:251-343-0835
Practice Address - Street 1:801 UNIVERSITY BLVD S
Practice Address - Street 2:STE B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-2923
Practice Address - Country:US
Practice Address - Phone:251-345-1717
Practice Address - Fax:251-343-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL32821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529912670Medicaid