Provider Demographics
NPI:1669666863
Name:SOUTH EAST DENTISTRY
Entity Type:Organization
Organization Name:SOUTH EAST DENTISTRY
Other - Org Name:ASHVILLE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-594-5171
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35953-0000
Mailing Address - Country:US
Mailing Address - Phone:205-594-5171
Mailing Address - Fax:205-594-7311
Practice Address - Street 1:125 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:AL
Practice Address - Zip Code:35953
Practice Address - Country:US
Practice Address - Phone:205-594-5171
Practice Address - Fax:205-594-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL53631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty