Provider Demographics
NPI:1679196307
Name:THE PEDIATRIC DENTAL CLINIC
Entity Type:Organization
Organization Name:THE PEDIATRIC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-766-0270
Mailing Address - Street 1:162 ANA DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 ANA DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1759
Practice Address - Country:US
Practice Address - Phone:256-766-0270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty