Provider Demographics
NPI:1790367126
Name:SAND MOUNTAIN FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SAND MOUNTAIN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-467-0387
Mailing Address - Street 1:211 DOGWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5601
Mailing Address - Country:US
Mailing Address - Phone:205-467-0387
Mailing Address - Fax:
Practice Address - Street 1:701 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5938
Practice Address - Country:US
Practice Address - Phone:205-467-0387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL171653Medicaid