Provider Demographics
NPI:1043879406
Name:PROCHAZKA, RENEE EVELYN (DMD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:EVELYN
Last Name:PROCHAZKA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BEACON PKWY E APT 601
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-1024
Mailing Address - Country:US
Mailing Address - Phone:423-834-1345
Mailing Address - Fax:
Practice Address - Street 1:1001 ODUM RD STE 103
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2695
Practice Address - Country:US
Practice Address - Phone:205-666-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00066311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice