Provider Demographics
NPI:1396421962
Name:PRUITT, CHANCE AUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:AUSTIN
Last Name:PRUITT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 COLUMBIANA RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-2518
Mailing Address - Country:US
Mailing Address - Phone:205-823-3223
Mailing Address - Fax:
Practice Address - Street 1:2816 COLUMBIANA RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-2518
Practice Address - Country:US
Practice Address - Phone:205-823-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007207-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist