Provider Demographics
NPI:1023130234
Name:COOSA COUNTY FAMILY DENTISTRY P.C.
Entity type:Organization
Organization Name:COOSA COUNTY FAMILY DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBRITTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-879-9761
Mailing Address - Street 1:PO BOX 660845
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35266
Mailing Address - Country:US
Mailing Address - Phone:205-879-9761
Mailing Address - Fax:205-879-6565
Practice Address - Street 1:RR 2 BOX 44
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:AL
Practice Address - Zip Code:35136-9507
Practice Address - Country:US
Practice Address - Phone:256-377-4647
Practice Address - Fax:256-377-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529922440Medicaid