Provider Demographics
NPI:1013304310
Name:SARRELL REGIONAL DENTAL CENTER FOR PUBLIC HEALTH, INC.
Entity Type:Organization
Organization Name:SARRELL REGIONAL DENTAL CENTER FOR PUBLIC HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-999-5006
Mailing Address - Street 1:230 E 10TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5784
Mailing Address - Country:US
Mailing Address - Phone:256-741-7340
Mailing Address - Fax:256-741-7373
Practice Address - Street 1:805 N MCKENZIE ST
Practice Address - Street 2:SUITE C
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-3544
Practice Address - Country:US
Practice Address - Phone:251-943-1189
Practice Address - Fax:251-943-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL172190Medicaid