Provider Demographics
NPI:1184251100
Name:BIG WAVE DENTISTRY LLC
Entity type:Organization
Organization Name:BIG WAVE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:HILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-231-7666
Mailing Address - Street 1:635 GLEN EAGLES AVE
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-9036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S ALSTON ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-1912
Practice Address - Country:US
Practice Address - Phone:251-213-9820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1447789045OtherFFS