Provider Demographics
NPI:1487013298
Name:ROBERT T UNDERWOOD DMD PC
Entity Type:Organization
Organization Name:ROBERT T UNDERWOOD DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-631-8066
Mailing Address - Street 1:1038 MOUNT OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-3443
Mailing Address - Country:US
Mailing Address - Phone:205-631-8066
Mailing Address - Fax:205-631-8021
Practice Address - Street 1:1038 MOUNT OLIVE RD
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-3443
Practice Address - Country:US
Practice Address - Phone:205-631-8066
Practice Address - Fax:205-631-8021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51096265OtherBLUE CROSS BLUE SHIELD OF AL
AL1841371929OtherNPI
AL009924885Medicaid
AL1255Medicare UPIN