| Evergreen Dental Center | |
|
119 Old Fort Road Suite B Fort Deposit AL 36032 | |
| (334) 227-4000 | |
| (334) 227-3770 |
| Full Name | Evergreen Dental Center |
|---|---|
| Speciality | Dentist |
| Location | 119 Old Fort Road, Fort Deposit, Alabama |
| Authorized Official Name and Position | Robert P Louis (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 2515783331 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Evergreen Dental Center Po Box 266 100 Edwina Street Evergreen AL 36401-0266 Ph: (251) 578-3331 | Evergreen Dental Center 119 Old Fort Road Suite B Fort Deposit AL 36032 Ph: (334) 227-4000 |
| NPI Number | 1518155373 |
|---|---|
| Provider Enumeration Date | 10/05/2007 |
| Last Update Date | 06/17/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518155373 | NPI | - | NPPES |
| 009910742 | Medicaid | AL | |
| 009995725 | Medicaid | AL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | DD5370-C (Alabama) | Primary |