Provider Demographics
NPI:1205250727
Name:SHELTON BEACH DENTAL CENTER INC
Entity type:Organization
Organization Name:SHELTON BEACH DENTAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-675-6730
Mailing Address - Street 1:PO BOX 11474
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36671-0474
Mailing Address - Country:US
Mailing Address - Phone:251-675-7630
Mailing Address - Fax:251-675-3637
Practice Address - Street 1:623 HIGHWAY 43 S
Practice Address - Street 2:SUITE A
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3633
Practice Address - Country:US
Practice Address - Phone:251-675-7630
Practice Address - Fax:251-675-7637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty