Provider Demographics
NPI:1275840415
Name:NORTH MOBILE DENTAL MEDICAID, LLC
Entity Type:Organization
Organization Name:NORTH MOBILE DENTAL MEDICAID, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHONN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARNI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-675-4313
Mailing Address - Street 1:1064 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-3720
Mailing Address - Country:US
Mailing Address - Phone:251-675-4313
Mailing Address - Fax:251-675-4355
Practice Address - Street 1:1064 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3720
Practice Address - Country:US
Practice Address - Phone:251-675-4313
Practice Address - Fax:251-675-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4781261QD0000X
AL4782261QD0000X
AL4784261QD0000X
AL5712261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental