Provider Demographics
NPI:1952774945
Name:PEDIATRIC DENTAL ASSOCIATES OF BIRMINGHAM, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF BIRMINGHAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-586-9922
Mailing Address - Street 1:1613 11TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4703
Mailing Address - Country:US
Mailing Address - Phone:205-586-9922
Mailing Address - Fax:
Practice Address - Street 1:1613 11TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-4703
Practice Address - Country:US
Practice Address - Phone:205-586-9922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty