Provider Demographics
NPI:1609374164
Name:PEDIATRIC DENTAL ASSOCIATES OF CULLMAN, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF CULLMAN, LLC
Other - Org Name:NASSETTA PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBLISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:205-453-0314
Mailing Address - Street 1:1705 MAIN AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-7207
Mailing Address - Country:US
Mailing Address - Phone:256-739-6000
Mailing Address - Fax:
Practice Address - Street 1:1705 MAIN AVE SW STE A
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-7207
Practice Address - Country:US
Practice Address - Phone:256-739-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0005181261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental