Provider Demographics
NPI:1851498059
Name:ALABAMA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:ALABAMA DENTAL PROFESSIONALS, P.C.
Other - Org Name:ROUSSEAU FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8434
Mailing Address - Street 1:136 PLAZA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1160
Mailing Address - Country:US
Mailing Address - Phone:256-464-3556
Mailing Address - Fax:256-464-3553
Practice Address - Street 1:136 PLAZA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1160
Practice Address - Country:US
Practice Address - Phone:256-464-3556
Practice Address - Fax:256-464-3553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALABAMA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-09614OtherBCBS OF AL PROVIDER NUMBE
AL515-34033OtherBCBS OF AL PROVIDER NUMBE