| Name: | Dental Associates of Madison, PLLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Limited Liability Company |
| Status: | Exists |
| Date of registration: | 12 Aug 2003 (21 years ago) |
| Entity Number: | 000-692-493 |
| Register Number: | 000692493 |
| Historical Names: |
Dental Associates of Madison, LLC
|
| ZIP code: | 35758 |
| County: | Madison |
| Place of Formation: | Madison County |
| Registered Office Street Address: | 2 NORTH JACKSON STREET - SUITE 605MONTGOMERY, AL 36104 |
| Principal Address: | 4027 SULLIVAN STREETMADISON, AL 35758 |
Activities
DENTISTRY/ORTHODONTICS
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1952543779 | 2009-03-25 | 2009-03-25 | 4072 SULLIVAN ST, SUITE A, MADISON, AL, 357583152, US | 4072 SULLIVAN ST, SUITE A, MADISON, AL, 357583152, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 256-772-9988 |
| Fax | 2567729991 |
Authorized person
| Name | MRS. TERRI WRENN |
| Role | ADMINISTRATIVE ASSISTANT |
| Phone | 2567729988 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | 4231 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS AL |
| Number | 51091741 |
| State | AL |
| Issuer | MEDICAID |
| Number | 000091741 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| HAWKINS, GREG | Member | 1408 7TH AVE SEDECATUR, AL 35601 |
| HAWKINS, RILEY | Member | 1408 7TH AVE SEDECATUR, AL 35601 |
| GALES, ANTONIO E | Member | 1408 7TH AVE SEDECATUR, AL 35601 |
| HARRIS, JEREMIAH L | Member | 1408 7TH AVE SEDECATUR, AL 35601 |
| HOOD, JOSHUA D | Member | 1408 7TH AVE SEDECATUR, AL 35601 |
| SUMNERS, SCOTT M | Member | No data |
| Name | Role | Address |
|---|---|---|
| C T CORPORATION SYSTEM | Agent | 2 NORHT JACKSON STREET SUITE 605MONTGOMERY, AL 36104 |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2022-11-09 | Name Change | Dental Associates of Madison, LLC | Dental Associates of Madison, PLLC |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
