Provider Demographics
NPI:1760477251
Name:DALEVILLE DENTAL, LLC
Entity Type:Organization
Organization Name:DALEVILLE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-598-4994
Mailing Address - Street 1:526 N DALEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36322-2000
Mailing Address - Country:US
Mailing Address - Phone:334-598-4994
Mailing Address - Fax:334-598-4342
Practice Address - Street 1:526 N DALEVILLE AVE
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36322-2000
Practice Address - Country:US
Practice Address - Phone:334-598-4994
Practice Address - Fax:334-598-4342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL45531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
820510OtherUCCI
AL51525448OtherBC/BS