Provider Demographics
NPI:1639363955
Name:WEST PRINCETON DENTAL CLINIC
Entity Type:Organization
Organization Name:WEST PRINCETON DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-788-2124
Mailing Address - Street 1:859 LOMB AVE SW
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-1257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:859 LOMB AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1257
Practice Address - Country:US
Practice Address - Phone:205-788-2124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1700-9799-94OtherINDIVIDUAL NPI NUMBER