Provider Demographics
NPI:1689217309
Name:STONECREEK DENTAL OF ALABAMA
Entity Type:Organization
Organization Name:STONECREEK DENTAL OF ALABAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-919-1750
Mailing Address - Street 1:1840 MONTCLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1840 MONTCLAIRE DR
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1408
Practice Address - Country:US
Practice Address - Phone:205-870-5445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONECREEK DENTAL OF ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty