Provider Demographics
NPI:1851697643
Name:ALABAMA DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:ALABAMA DENTAL PROFESSIONALS PC
Other - Org Name:BROAD STREET DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUP
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:1202 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2512
Mailing Address - Country:US
Mailing Address - Phone:256-259-5955
Mailing Address - Fax:256-259-5954
Practice Address - Street 1:1202 S BROAD ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2512
Practice Address - Country:US
Practice Address - Phone:256-259-5955
Practice Address - Fax:256-259-5954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALABAMA DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4762122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty