Provider Demographics
NPI:1104330950
Name:UNIVERSITY ORTHODONTICS LLC
Entity type:Organization
Organization Name:UNIVERSITY ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:GOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:205-553-2524
Mailing Address - Street 1:641 HELEN KELLER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-2983
Mailing Address - Country:US
Mailing Address - Phone:205-553-2524
Mailing Address - Fax:205-553-6617
Practice Address - Street 1:641 HELEN KELLER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-2983
Practice Address - Country:US
Practice Address - Phone:205-553-2524
Practice Address - Fax:205-553-6617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty