Provider Demographics
NPI:1043815590
Name:PDA ORTHODONTICS TRUSSVILLE PLLC
Entity type:Organization
Organization Name:PDA ORTHODONTICS TRUSSVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:205-910-0143
Mailing Address - Street 1:5336 STADIUM TRACE PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4581
Mailing Address - Country:US
Mailing Address - Phone:205-988-9678
Mailing Address - Fax:205-988-9065
Practice Address - Street 1:4901 DEERFOOT PKWY STE 101
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2697
Practice Address - Country:US
Practice Address - Phone:205-508-7135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty