Provider Demographics
NPI:1598881716
Name:PEDIATRIC DENTISTRY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-745-6443
Mailing Address - Street 1:121 N 20TH ST
Mailing Address - Street 2:SUITE 20-C
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5449
Mailing Address - Country:US
Mailing Address - Phone:334-745-6443
Mailing Address - Fax:334-745-3444
Practice Address - Street 1:121 N 20TH ST
Practice Address - Street 2:SUITE 20-C
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5449
Practice Address - Country:US
Practice Address - Phone:334-745-6443
Practice Address - Fax:334-745-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty