Provider Demographics
NPI:1083445571
Name:PATRIOT DENTAL SNEAD LLC
Entity type:Organization
Organization Name:PATRIOT DENTAL SNEAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LUCKIE
Authorized Official - Last Name:VANDERVOORT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-466-7188
Mailing Address - Street 1:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:SNEAD
Mailing Address - State:AL
Mailing Address - Zip Code:35952-0627
Mailing Address - Country:US
Mailing Address - Phone:205-466-7188
Mailing Address - Fax:205-466-8188
Practice Address - Street 1:88223 US HIGHWAY 278
Practice Address - Street 2:
Practice Address - City:SNEAD
Practice Address - State:AL
Practice Address - Zip Code:35952-9643
Practice Address - Country:US
Practice Address - Phone:205-466-7188
Practice Address - Fax:205-466-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty