Provider Demographics
NPI:1336973999
Name:SOUTHERN ROOTS FAMILY AND COSMETIC DENTISTRY
Entity type:Organization
Organization Name:SOUTHERN ROOTS FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:P
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:251-342-0380
Mailing Address - Street 1:6154 OMNI PARK DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-5195
Mailing Address - Country:US
Mailing Address - Phone:251-414-5142
Mailing Address - Fax:
Practice Address - Street 1:6154 OMNI PARK DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5195
Practice Address - Country:US
Practice Address - Phone:251-414-5142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-27
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental