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Kenneth W. Chancey, DMD, LLC

Details

Name: Kenneth W. Chancey, DMD, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Dissolved
Date of registration: 06 Jan 2006 (19 years ago) (Companies founded in January 2006)
Date of dissolution: 22 Aug 2019
Entity Number: 000-473-197
Register Number: 000473197
ZIP code: 36330 (Companies in Coffee, 36330)
County: Coffee
Place of Formation: Coffee County
Registered Office Street Address: 442 GLOVER AVEENTERPRISE, AL 36330
Principal Address: ENTERPRISE, AL

Activities DENTISTRY PRACTICE

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1083966386 2012-10-10 2012-10-10 534 BOLL WEEVIL CIR, ENTERPRISE, AL, 363304012, US 534 BOLL WEEVIL CIR, ENTERPRISE, AL, 363304012, US

Contacts
Phone +1 334-347-0036
Fax 3342082217

Authorized person
Name MR. KENNETH W CHANCEY
Role OWNER/DENTIST
Phone 3343470036

Taxonomy
Taxonomy Code 305R00000X - Preferred Provider Organization
License Number 3091
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 009915475
State AL
Issuer BLUE CROSS BLUE SHIELD
Number 51091102
State AL
Issuer UNITED CONCORDIA
Number 000825887
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
KENNETH W. CHANCEY, DMD, LLC 401(K) PLAN 2019 275427741 2020-07-09 KENNETH W. CHANCEY, DMD, LLC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621210
Sponsor’s telephone number 3343470036
Plan sponsor’s address 534 BOLL WEEVIL CIRCLE, ENTERPRISE, AL, 36330

Signature of
Role Plan administrator
Date 2020-07-09
Name of individual signing KENNETH CHANCEY
KENNETH W. CHANCEY, DMD, LLC 401(K) PLAN 2019 275427741 2020-07-09 KENNETH W. CHANCEY, DMD, LLC 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621210
Sponsor’s telephone number 3343470036
Plan sponsor’s address 534 BOLL WEEVIL CIRCLE, ENTERPRISE, AL, 36330

Signature of
Role Plan administrator
Date 2020-07-09
Name of individual signing KENNETH CHANCEY
KENNETH W. CHANCEY, DMD, LLC 401(K) PLAN 2018 275427741 2019-10-07 KENNETH W. CHANCEY, DMD, LLC 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621210
Sponsor’s telephone number 3343470036
Plan sponsor’s address 534 BOLL WEEVIL CIRCLE, ENTERPRISE, AL, 36330

Signature of
Role Plan administrator
Date 2019-10-07
Name of individual signing KENNETH CHANCEY
KENNETH W. CHANCEY, DMD, LLC 401(K) PLAN 2017 275427741 2018-08-23 KENNETH W. CHANCEY, DMD, LLC 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621210
Sponsor’s telephone number 3343470036
Plan sponsor’s address 534 BOLL WEEVIL CIRCLE, ENTERPRISE, AL, 36330

Signature of
Role Plan administrator
Date 2018-08-23
Name of individual signing BRANDON M. TURNER
KENNETH W. CHANCEY, DMD, LLC 401(K) PLAN 2016 275427741 2017-10-16 KENNETH W. CHANCEY, DMD, LLC 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621210
Sponsor’s telephone number 3343470036
Plan sponsor’s address 534 BOLL WEEVIL CIRCLE, ENTERPRISE, AL, 36330

Signature of
Role Plan administrator
Date 2017-10-16
Name of individual signing BRANDON M. TURNER

Agent

Name Role
CHANCEY, KENNETH W Agent

Member

Name Role
CHANCEY, KENNETH W Member

Related by officers

CHANCEY, KENNETH W

Friends of Alabama Nursing Home Residents Inc.

Related by address

442 GLOVER AVEENTERPRISE, AL 36330

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Date of last update: 14 Aug 2024

Sources: Alabama Secretary of State

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