Provider Demographics
NPI:1255740122
Name:MOBILE BAY DENTAL, LLC
Entity type:Organization
Organization Name:MOBILE BAY DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-706-7960
Mailing Address - Street 1:1651 SCHILLINGER RD N
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-7409
Mailing Address - Country:US
Mailing Address - Phone:251-706-7960
Mailing Address - Fax:
Practice Address - Street 1:1651 SCHILLINGER RD N
Practice Address - Street 2:
Practice Address - City:SEMMES
Practice Address - State:AL
Practice Address - Zip Code:36575-7409
Practice Address - Country:US
Practice Address - Phone:251-706-7960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-779-TA-178152W00000X
AL52261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10161482Medicaid