Provider Demographics
NPI:1962793893
Name:DANDRIDGE DENTAL PC
Entity type:Organization
Organization Name:DANDRIDGE DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-699-2220
Mailing Address - Street 1:1435 ROSS CLARK CIR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-4744
Mailing Address - Country:US
Mailing Address - Phone:334-699-2220
Mailing Address - Fax:334-699-2223
Practice Address - Street 1:1435 ROSS CLARK CIR
Practice Address - Street 2:SUITE A-1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4744
Practice Address - Country:US
Practice Address - Phone:334-699-2220
Practice Address - Fax:334-699-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5492302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization