| Name: | North Jackson Dental Care, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 12 Dec 1997 (27 years ago) |
| Entity Number: | 000-191-931 |
| Register Number: | 000191931 |
| County: | Jackson |
| Place of Formation: | Jackson County |
| Principal Address: | STEVENSON, AL |
| Registered Office Street Address: | 105 ADAMS STREETSTEVENSON, AL 35772 |
| Registered Office Street Address ZIP Code: | 35772 |
| Authorized Capital: | 1,000 |
Activities
DENTAL SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1659456879 | 2006-10-26 | 2020-08-22 | 105 ADAMS STREET, STEVENSON, AL, 35772, US | 105 ADAMS STREET, STEVENSON, AL, 35772, US | |||||||||||||||||||||||||||||
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| Phone | +1 256-437-2191 |
| Fax | 2564371066 |
Authorized person
| Name | DR. STEPHEN SCOTT SHEPHERD |
| Role | DR PRESIDENT OF CORPORATION |
| Phone | 2564372191 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | 3796 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 3093026 |
| State | TN |
| Issuer | UNITED CONCORDIA |
| Number | 595965 |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NORTH JACKSON DENTAL CARE, P.C. PROFIT SHARING PLAN | 2011 | 631189507 | 2012-05-23 | NORTH JACKSON DENTAL CARE, P.C. | 7 | |||||||||||||||||||||||||||||||||||||
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| Administrator’s EIN | 631189507 |
| Plan administrator’s name | NORTH JACKSON DENTAL CARE, P.C. |
| Plan administrator’s address | 105 ADAMS STREET, STEVENSON, AL, 35772 |
| Administrator’s telephone number | 2564372191 |
Signature of
| Role | Plan administrator |
| Date | 2012-05-23 |
| Name of individual signing | SCOTT SHEPHERD, D.M.D. |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1998-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2564372191 |
| Plan sponsor’s address | 105 ADAMS STREET, STEVENSON, AL, 35772 |
Plan administrator’s name and address
| Administrator’s EIN | 631189507 |
| Plan administrator’s name | NORTH JACKSON DENTAL CARE, P.C. |
| Plan administrator’s address | 105 ADAMS STREET, STEVENSON, AL, 35772 |
| Administrator’s telephone number | 2564372191 |
Signature of
| Role | Plan administrator |
| Date | 2011-07-12 |
| Name of individual signing | SCOTT SHEPHERD, D.M.D. |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1998-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2564372191 |
| Plan sponsor’s address | 105 ADAMS STREET, STEVENSON, AL, 35772 |
Plan administrator’s name and address
| Administrator’s EIN | 631189507 |
| Plan administrator’s name | NORTH JACKSON DENTAL CARE, P.C. |
| Plan administrator’s address | 105 ADAMS STREET, STEVENSON, AL, 35772 |
| Administrator’s telephone number | 2564372191 |
Signature of
| Role | Plan administrator |
| Date | 2010-07-14 |
| Name of individual signing | SCOTT SHEPHERD, D.M.D. |
| Role | Employer/plan sponsor |
| Date | 2010-07-14 |
| Name of individual signing | SCOTT SHEPHERD, D.M.D. |
| Name | Role | Address |
|---|---|---|
| SHEPHERD, SCOTT | Agent | 6302 37TH CT NETUSCALOOSA, AL 35406 |
| Name | Role | Address |
|---|---|---|
| SHEPHERD, SCOTT | Incorporator | 6302 37TH CT NETUSCALOOSA, AL 35406 |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
