Provider Demographics
NPI:1043954647
Name:PEDIATRIC DENTAL ASSOCIATES OF HOOVER, LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF HOOVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:
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:
Mailing Address - Fax:
Practice Address - Street 1:5336 STADIUM TRACE PKWY STE 112
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4581
Practice Address - Country:US
Practice Address - Phone:205-988-9678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty