Provider Demographics
NPI:1609993591
Name:CARDINAL DENTAL LLC
Entity Type:Organization
Organization Name:CARDINAL DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-347-6456
Mailing Address - Street 1:P.O. BOX 311870
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331
Mailing Address - Country:US
Mailing Address - Phone:334-347-6456
Mailing Address - Fax:334-393-3817
Practice Address - Street 1:442 GLOVER AVE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-347-6456
Practice Address - Fax:334-393-3817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1839862OtherUNITED CONCORDIA