Provider Demographics
NPI:1629598750
Name:GENESIS DENTAL GROUP SMILES ON 11TH LLC
Entity Type:Organization
Organization Name:GENESIS DENTAL GROUP SMILES ON 11TH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-676-2320
Mailing Address - Street 1:3150 ZELDA CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2607
Mailing Address - Country:US
Mailing Address - Phone:334-676-2320
Mailing Address - Fax:334-593-2724
Practice Address - Street 1:1010 W 11TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2042
Practice Address - Country:US
Practice Address - Phone:850-763-3622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty