Evergreen Dental Center

Primary specialty

DentistTaxonomy code 122300000X

License

DD5370-C Issued in AL

Legal business name

EVERGREEN DENTAL CENTER

Doing business as

Fort Deposit Dental Center

Practice address

119 Old Fort Road
Suite B
Fort Deposit, AL 36032

Phone

(334) 227-4000

Fax

(334) 227-3770

NPI assigned

Oct 5, 2007

Last updated

Jun 17, 2008By the provider in NPPES

Organization subpart

Yes

Parent organization

EVERGREEN DENTAL CENTERAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Robert P Louis, DDS MPH

Title

Executive Director

Phone

(251) 578-3331

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Fort Deposit Dental Center Doing business as

Tax ID family

Evergreen Dental Center2 organizations share this tax ID, including this one

Part of

Evergreen Dental Center

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Evergreen Dental Center

  • Dentist
  • Evergreen, AL
  • NPI 1467526038
  NPD tax ID

Locations

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

• Evergreen Dental Center

  • Dentist
  • Evergreen, AL
  • NPI 1467526038
  NPPES parent name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1191542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213660800000",
    "number": "1518155373",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 266",
            "address_2": "100 EDWINA STREET",
            "city": "EVERGREEN",
            "state": "AL",
            "postal_code": "364010266",
            "telephone_number": "251-578-3331",
            "fax_number": "251-578-5277"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "119 OLD FORT ROAD",
            "address_2": "SUITE B",
            "city": "FORT DEPOSIT",
            "state": "AL",
            "postal_code": "36032",
            "telephone_number": "334-227-4000",
            "fax_number": "334-227-3770"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN DENTAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EVERGREEN DENTAL CENTER",
        "enumeration_date": "2007-10-05",
        "last_updated": "2008-06-17",
        "status": "A",
        "authorized_official_last_name": "LOUIS",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "251-578-3331",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS MPH"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "AL",
            "license": "DD5370-C",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009995725",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009910742",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fort Deposit Dental Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Able, LLC
• Tykerria Axel
• Herbert Lamar Barber Jr., RN, BSN
• Fort Deposit Drug Pharmacy LLC
• Latarshe Hare
• Kimberly Nacole Jordan
• Phillip N. Golomb, MD PA
• Tri County Medical Center, Inc (Yearwood Medical Clinic)

• Dentist in Fort Deposit, AL
• Providers in Fort Deposit, AL by specialty
• Dentist in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.