Provider Demographics
NPI:1932354727
Name:CENTER FOR COSMETIC AND RESTORATIVE DENTISTRY
Entity Type:Organization
Organization Name:CENTER FOR COSMETIC AND RESTORATIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-339-6762
Mailing Address - Street 1:2820 LURLEEN B WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3249
Mailing Address - Country:US
Mailing Address - Phone:205-339-6762
Mailing Address - Fax:205-339-9103
Practice Address - Street 1:2820 LURLEEN B WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3249
Practice Address - Country:US
Practice Address - Phone:205-339-6762
Practice Address - Fax:205-339-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48591223G0001X
AL50071223G0001X
AL52401223G0001X
AL54671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1023199213OtherINDIVIDUAL NPI
AL1972679967OtherINDIVIDUAL NPI
AL1356425649OtherINDIVIDUAL NPI
AL1851475149OtherINDIVIDUAL NPI