Provider Demographics
NPI:1841046703
Name:PDA OF TRUSSVILLE
Entity type:Organization
Organization Name:PDA OF TRUSSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BAKER
Authorized Official - Last Name:CHAMBLISS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-453-0314
Mailing Address - Street 1:50 CROPWELL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35128-7552
Mailing Address - Country:US
Mailing Address - Phone:678-628-8303
Mailing Address - Fax:256-285-1485
Practice Address - Street 1:4643 CAMP COLEMAN RD STE 101
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2838
Practice Address - Country:US
Practice Address - Phone:678-628-8303
Practice Address - Fax:256-285-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty