Provider Demographics
NPI:1891017836
Name:EAST ALABAMA DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:EAST ALABAMA DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-749-5014
Mailing Address - Street 1:1945 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5403
Mailing Address - Country:US
Mailing Address - Phone:334-749-5014
Mailing Address - Fax:334-749-9823
Practice Address - Street 1:1945 1ST AVE
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5403
Practice Address - Country:US
Practice Address - Phone:334-749-5014
Practice Address - Fax:334-749-9823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00048001223G0001X
AL00053671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty