Provider Demographics
NPI:1689769069
Name:DECATUR DENTAL CENTER L.L.C.
Entity Type:Organization
Organization Name:DECATUR DENTAL CENTER L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-353-8696
Mailing Address - Street 1:2112A DANVILLE RD., SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601
Mailing Address - Country:US
Mailing Address - Phone:256-353-8696
Mailing Address - Fax:256-353-7388
Practice Address - Street 1:2112A DANVILLE RD., SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-353-8696
Practice Address - Fax:256-353-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX ID #