Provider Demographics
NPI:1467143586
Name:TUSCALOOSA DENTAL LLC
Entity Type:Organization
Organization Name:TUSCALOOSA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-875-1330
Mailing Address - Street 1:2425 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7756
Mailing Address - Country:US
Mailing Address - Phone:334-875-1330
Mailing Address - Fax:
Practice Address - Street 1:1402 VETERANS MEMORIAL PKWY
Practice Address - Street 2:SUITE A & B
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404
Practice Address - Country:US
Practice Address - Phone:334-875-1330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty