Provider Demographics
NPI:1942809355
Name:ETHERTON FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:ETHERTON FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ETHERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-756-4178
Mailing Address - Street 1:6 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-3665
Mailing Address - Country:US
Mailing Address - Phone:334-756-4178
Mailing Address - Fax:334-756-5884
Practice Address - Street 1:6 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3665
Practice Address - Country:US
Practice Address - Phone:334-756-4178
Practice Address - Fax:334-756-5884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental