| Name: | Southlake Dental Care Management, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Exists |
| Date of registration: | 18 Aug 2015 (9 years ago) |
| Entity Number: | 000-341-860 |
| Register Number: | 000341860 |
| County: | Jefferson |
| Place of Formation: | Jefferson County |
| Registered Office Street Address: | 500 OFFICE PARK DRIVE SUITE 100BIRMINGHAM, AL 35223 |
| Registered Office Street Address ZIP Code: | 35223 |
| Authorized Capital: | 10,000 @ $1 PV |
Activities
DENTAL CARE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124472956 | 2016-04-18 | 2016-04-18 | 4501 SOUTHLAKE PKWY, HOOVER, AL, 352443644, US | 4501 SOUTHLAKE PKWY, HOOVER, AL, 352443644, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 205-988-5656 |
| Fax | 2059883972 |
Authorized person
| Name | DR. KAROL MEDINA POCZATEK |
| Role | DENTIST |
| Phone | 2059885656 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | 3410 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 4159 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 5772 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 5257 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 51171 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 6258 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 122300000X - Dentist |
| License Number | 5423 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 126341 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| PARKER, LORRIE M | Agent | 500 OFFICE PARK DRIVE SUITE 100BIRMINGHAM, AL 35223 |
| Name | Role | Address |
|---|---|---|
| POCZATEK, KAROL | Director | 4501 SOUTHLAKE PARKWAY SUITE 100BIRMINGHAM, AL 35244 |
| Name | Role | Address |
|---|---|---|
| PARKER, LORRIE M | Incorporator | 500 OFFICE PARK DRIVE SUITE 100BIRMINGHAM, AL 35223 |
Date of last update: 03 Aug 2024
Sources: Alabama Secretary of State
