Provider Demographics
NPI:1710306311
Name:HAZEL GREEN DENTAL
Entity Type:Organization
Organization Name:HAZEL GREEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-829-8878
Mailing Address - Street 1:1111 BLUEFIELD AVE SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-2512
Mailing Address - Country:US
Mailing Address - Phone:256-829-8878
Mailing Address - Fax:
Practice Address - Street 1:14244 HIGHWAY 231/431 N
Practice Address - Street 2:
Practice Address - City:HAZEL GREEN
Practice Address - State:AL
Practice Address - Zip Code:35750
Practice Address - Country:US
Practice Address - Phone:256-829-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL58221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty