Provider Demographics
NPI:1588212609
Name:ALFRED FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ALFRED FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFRED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-560-7804
Mailing Address - Street 1:2815 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-2903
Mailing Address - Country:US
Mailing Address - Phone:318-560-7804
Mailing Address - Fax:
Practice Address - Street 1:2815 CRESTWOOD LN
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-2903
Practice Address - Country:US
Practice Address - Phone:318-560-7804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental