Provider Demographics
NPI:1700056124
Name:PEDIATRIC DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHAMBLISS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-338-4227
Mailing Address - Street 1:2806 DR JOHN HAYNES DR STE B
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35125-1485
Mailing Address - Country:US
Mailing Address - Phone:205-338-4227
Mailing Address - Fax:205-338-4204
Practice Address - Street 1:2806 DR JOHN HAYNES DR STE B
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-1485
Practice Address - Country:US
Practice Address - Phone:205-338-4227
Practice Address - Fax:205-338-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO51811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty