Provider Demographics
NPI:1861122566
Name:PALESANO, ROSS TAYLOR (DMD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:TAYLOR
Last Name:PALESANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 ELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-7128
Mailing Address - Country:US
Mailing Address - Phone:251-509-4651
Mailing Address - Fax:
Practice Address - Street 1:111 E RIDGELEY ST
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-2013
Practice Address - Country:US
Practice Address - Phone:251-368-3237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0007046-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD-0007046-C1Medicaid