Provider Demographics
NPI:1790066728
Name:COMPLETE DENTAL OF MOBILE
Entity Type:Organization
Organization Name:COMPLETE DENTAL OF MOBILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:251-661-1003
Mailing Address - Street 1:5651 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-1617
Mailing Address - Country:US
Mailing Address - Phone:251-661-1003
Mailing Address - Fax:251-661-2709
Practice Address - Street 1:5651 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-1617
Practice Address - Country:US
Practice Address - Phone:251-661-1003
Practice Address - Fax:251-661-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-03
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5565261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental