Provider Demographics
NPI:1902297690
Name:AESTHETIC AND RECONSTRUCTIVE DENTISTRY, LLC
Entity Type:Organization
Organization Name:AESTHETIC AND RECONSTRUCTIVE DENTISTRY, LLC
Other - Org Name:MADISON PROSTHODONTICS: AESTHETIC AND RECONSTRUCTIVE DENTISTRY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAMIN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:WILTZ
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD, CDT
Authorized Official - Phone:256-319-3256
Mailing Address - Street 1:1041 BALCH RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8343
Mailing Address - Country:US
Mailing Address - Phone:256-319-3256
Mailing Address - Fax:256-319-3257
Practice Address - Street 1:1041 BALCH RD
Practice Address - Street 2:SUITE 180
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8343
Practice Address - Country:US
Practice Address - Phone:256-319-3256
Practice Address - Fax:256-319-3257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL59281223P0700X
AL233720-00292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No292200000XLaboratoriesDental LaboratoryGroup - Single Specialty