Provider Demographics
NPI:1770752073
Name:FAMILY DENTISTRY
Entity type:Organization
Organization Name:FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-593-6322
Mailing Address - Street 1:1163 SEAY AVE
Mailing Address - Street 2:P.O. BOX 577
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957
Mailing Address - Country:US
Mailing Address - Phone:256-593-6322
Mailing Address - Fax:256-593-2444
Practice Address - Street 1:1163 SEAY AVE
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-6242
Practice Address - Country:US
Practice Address - Phone:256-593-6322
Practice Address - Fax:256-593-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL90799OtherBCBS