1114266558 NPI number — GENERAL DENTISTRY AND SAME DAY DENTURE CLINIC,LLC

Table of content: KENNETH GRANADOS PA (NPI 1225486251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114266558 NPI number — GENERAL DENTISTRY AND SAME DAY DENTURE CLINIC,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENERAL DENTISTRY AND SAME DAY DENTURE CLINIC,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114266558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 BRIARWOOD AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PAYNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35967-8473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-845-3050
Provider Business Mailing Address Fax Number:
256-845-3057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
940 GILBERT FERRY RD SE
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
ATTALLA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35954-3338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-845-3050
Provider Business Practice Location Address Fax Number:
256-845-3057
Provider Enumeration Date:
02/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT/MEMBER
Authorized Official Telephone Number:
256-845-3050

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5489 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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