Provider Demographics
NPI:1639552284
Name:ALABAMA DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:ALABAMA DENTAL PROFESSIONALS PC
Other - Org Name:BAYSIDE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8330
Mailing Address - Street 1:19354 GREENO RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3834
Mailing Address - Country:US
Mailing Address - Phone:251-990-8885
Mailing Address - Fax:251-990-5701
Practice Address - Street 1:19354 GREENO RD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3834
Practice Address - Country:US
Practice Address - Phone:251-990-8885
Practice Address - Fax:251-990-5701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALABAMA DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty