Pinson Family Dentistry, P.C.

Contacts

Fax	2056808806

Authorized person

Name	DR. GERALD DANE GROVENSTEIN JR.
Role	PRESIDENT
Phone	2056801120

Taxonomy

Taxonomy Code	261QD0000X - Dental Clinic/Center
License Number	6302
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	1659721587
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2024-09-25
Name of individual signing	MICHAEL VANDERFORD
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2023-09-26
Name of individual signing	MICHAEL VANDERFORD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2022-08-23
Name of individual signing	GERALD DANE GROVENSTEIN, JR

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2021-07-09
Name of individual signing	GERALD DANE GROVENSTEIN, JR

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2020-08-15
Name of individual signing	GERALD DANE GROVENSTEIN, JR

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 35126

Signature of

Role	Plan administrator
Date	2019-09-30
Name of individual signing	GERALD DANE GROVENSTEIN, JR

Three-digit plan number (PN)	001
Effective date of plan	2018-01-01
Business code	621210
Sponsor’s telephone number	2056801120
Plan sponsor’s DBA name	DEERFOOT DENTAL
Plan sponsor’s address	6727 DEERFOOT PKWY, PINSON, AL, 351263093

Signature of

Role	Plan administrator
Date	2019-09-03
Name of individual signing	GERALD GROVENSTEIN