Provider Demographics
NPI:1154748218
Name:REGIONAL DENTAL CENTER
Entity type:Organization
Organization Name:REGIONAL DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-435-4464
Mailing Address - Street 1:505 PELHAM RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-2775
Mailing Address - Country:US
Mailing Address - Phone:256-435-4464
Mailing Address - Fax:256-435-2079
Practice Address - Street 1:505 PELHAM RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-2775
Practice Address - Country:US
Practice Address - Phone:256-435-4464
Practice Address - Fax:256-435-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3308OtherDELTA
AL51097747OtherBLUE CROSS BLUE SHEILD OF ALABAMA
AL000097747Medicaid
AL793127OtherUNITED CONCORDIA