Provider Demographics
NPI:1689920852
Name:GARDENDALE DENTAL
Entity Type:Organization
Organization Name:GARDENDALE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-631-1879
Mailing Address - Street 1:2334 DECATUR HWY
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2396
Mailing Address - Country:US
Mailing Address - Phone:205-631-1879
Mailing Address - Fax:205-631-1887
Practice Address - Street 1:2334 DECATUR HWY
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2396
Practice Address - Country:US
Practice Address - Phone:205-631-1879
Practice Address - Fax:205-631-1887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service