Provider Demographics
NPI:1043344617
Name:DANIEL, ROOSEVELT ALFONSO (DDS)
Entity type:Individual
Prefix:DR
First Name:ROOSEVELT
Middle Name:ALFONSO
Last Name:DANIEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N HAARDT DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36105-1646
Mailing Address - Country:US
Mailing Address - Phone:334-834-4188
Mailing Address - Fax:334-834-9647
Practice Address - Street 1:524 E EDGEMONT AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-1321
Practice Address - Country:US
Practice Address - Phone:334-834-9647
Practice Address - Fax:334-834-3716
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51091556OtherBCBSAL
AL000091556Medicaid
AL91556Medicare UPIN