Provider Demographics
NPI:1992963193
Name:NASSETTA PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:NASSETTA PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:NASSETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-586-5806
Mailing Address - Street 1:1705 MAIN AVE SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-7206
Mailing Address - Country:US
Mailing Address - Phone:256-739-6000
Mailing Address - Fax:
Practice Address - Street 1:1705 MAIN AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-7206
Practice Address - Country:US
Practice Address - Phone:256-739-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty