Provider Demographics
NPI:1922193002
Name:MOBILE BAY DENTAL LLC
Entity Type:Organization
Organization Name:MOBILE BAY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:HANKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-433-7717
Mailing Address - Street 1:301 SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36602-4037
Mailing Address - Country:US
Mailing Address - Phone:251-433-7717
Mailing Address - Fax:251-433-9384
Practice Address - Street 1:301 SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36602-4037
Practice Address - Country:US
Practice Address - Phone:251-433-7717
Practice Address - Fax:251-433-9384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5226122300000X
ALS-779-TA-178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529912860Medicaid
AL14048OtherBCBS OF ALABAMA