Provider Demographics
NPI:1497159826
Name:WILLIAM G EASTBURN DMD INC
Entity Type:Organization
Organization Name:WILLIAM G EASTBURN DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:EASTBURN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:251-344-2126
Mailing Address - Street 1:5368 ZEIGLER BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-4334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5368 ZEIGLER BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-4334
Practice Address - Country:US
Practice Address - Phone:251-344-2126
Practice Address - Fax:251-344-2168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL44291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009987090Medicaid