Provider Demographics
NPI:1851585079
Name:PEDIATRIC AND ADOLESCENT DENTISTRY, LLC
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-982-0112
Mailing Address - Street 1:5346 STADIUM TRACE PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4582
Mailing Address - Country:US
Mailing Address - Phone:205-982-0112
Mailing Address - Fax:205-982-0737
Practice Address - Street 1:5346 STADIUM TRACE PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-4582
Practice Address - Country:US
Practice Address - Phone:205-982-0112
Practice Address - Fax:205-982-0737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL51221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51540792OtherBC/BS