Provider Demographics
NPI:1619403607
Name:DIAMOND SMILES DENTISTRY, INC
Entity Type:Organization
Organization Name:DIAMOND SMILES DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-988-9700
Mailing Address - Street 1:5336 STADIUM TRACE PKWY
Mailing Address - Street 2:STE 102
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4580
Mailing Address - Country:US
Mailing Address - Phone:205-988-9700
Mailing Address - Fax:205-988-4191
Practice Address - Street 1:5336 STADIUM TRACE PKWY
Practice Address - Street 2:STE 102
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4580
Practice Address - Country:US
Practice Address - Phone:205-988-9700
Practice Address - Fax:205-988-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL170194861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty