Provider Demographics
NPI:1801077334
Name:TRUSSVILLE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:TRUSSVILLE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-655-1000
Mailing Address - Street 1:123 N CHALKVILLE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1376
Mailing Address - Country:US
Mailing Address - Phone:205-655-1000
Mailing Address - Fax:205-655-7196
Practice Address - Street 1:123 N CHALKVILLE RD
Practice Address - Street 2:STE 1
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1376
Practice Address - Country:US
Practice Address - Phone:205-655-1000
Practice Address - Fax:205-655-7196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL559929290Medicaid