Provider Demographics
NPI:1265956825
Name:WIREGRASS DENTAL CENTER LLC
Entity type:Organization
Organization Name:WIREGRASS DENTAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:NIX
Authorized Official - Last Name:UNTERKOFLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-347-3061
Mailing Address - Street 1:2 EAST POINTE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330
Mailing Address - Country:US
Mailing Address - Phone:334-347-3061
Mailing Address - Fax:
Practice Address - Street 1:2 E POINTE CT
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-1392
Practice Address - Country:US
Practice Address - Phone:334-347-3061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21381261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental