Provider Demographics
NPI:1518155373
Name:EVERGREEN DENTAL CENTER
Entity Type:Organization
Organization Name:EVERGREEN DENTAL CENTER
Other - Org Name:FORT DEPOSIT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MPH
Authorized Official - Phone:251-578-3331
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:100 EDWINA STREET
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-0266
Mailing Address - Country:US
Mailing Address - Phone:251-578-3331
Mailing Address - Fax:251-578-5277
Practice Address - Street 1:119 OLD FORT ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:FORT DEPOSIT
Practice Address - State:AL
Practice Address - Zip Code:36032
Practice Address - Country:US
Practice Address - Phone:334-227-4000
Practice Address - Fax:334-227-3770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-05
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDD5370-C122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910742Medicaid
AL009995725Medicaid