Provider Demographics
NPI:1760835078
Name:GENESIS DENTAL GROUP BRIERFIELD PC
Entity Type:Organization
Organization Name:GENESIS DENTAL GROUP BRIERFIELD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-281-2451
Mailing Address - Street 1:19330 HIGHWAY 139
Mailing Address - Street 2:
Mailing Address - City:BRIERFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35035-3658
Mailing Address - Country:US
Mailing Address - Phone:205-665-2723
Mailing Address - Fax:205-665-1037
Practice Address - Street 1:19330 HIGHWAY 139
Practice Address - Street 2:
Practice Address - City:BRIERFIELD
Practice Address - State:AL
Practice Address - Zip Code:35035-3658
Practice Address - Country:US
Practice Address - Phone:205-665-2723
Practice Address - Fax:205-665-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty