| Name: | Evergreen Dental Center, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 06 Aug 2004 (20 years ago) (Companies founded in August 2004) |
| Entity Number: | 000-236-698 |
| Register Number: | 000236698 |
| ZIP code: | 36401 (Companies in Conecuh, 36401) |
| County: | Conecuh |
| Place of Formation: | Conecuh County |
| Principal Address: | EVERGREEN, AL |
| Registered Office Street Address: | 100 EDWINA AVEEVERGREEN, AL 36401 |
| Authorized Capital: | $5,000 |
Activities
DENTISTRY PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1518155373 | 2007-10-05 | 2008-06-17 | PO BOX 266, 100 EDWINA STREET, EVERGREEN, AL, 364010266, US | 119 OLD FORT ROAD, SUITE B, FORT DEPOSIT, AL, 36032, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 251-578-3331 |
| Fax | 2515785277 |
| Phone | +1 334-227-4000 |
| Fax | 3342273770 |
Authorized person
| Name | DR. ROBERT P LOUIS |
| Role | EXECUTIVE DIRECTOR |
| Phone | 2515783331 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | DD5370-C |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 009910742 |
| State | AL |
| Issuer | MEDICAID |
| Number | 009995725 |
| State | AL |
| Name | Role |
|---|---|
| LOUIS, ROBERT P | Agent |
| Name | Role | Address |
|---|---|---|
| SMITH, DAVIS H | Incorporator | 445 DEXTER AVE STE 9075MONTGOMERY, AL 36104 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
