Provider Demographics
NPI:1952661225
Name:TRUSSVILLE DENTISTRY PC
Entity Type:Organization
Organization Name:TRUSSVILLE DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:F
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-661-2201
Mailing Address - Street 1:3713 MARY TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3261
Mailing Address - Country:US
Mailing Address - Phone:205-661-2201
Mailing Address - Fax:205-661-2331
Practice Address - Street 1:3713 MARY TAYLOR RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3261
Practice Address - Country:US
Practice Address - Phone:205-661-2201
Practice Address - Fax:205-661-2331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty