| Name: | SHOAL CREEK DENTAL LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 04 May 2018 (7 years ago) (Companies founded in May 2018) |
| Entity Number: | 000-517-785 |
| Register Number: | 000517785 |
| ZIP code: | 35645 (Companies in Lauderdale, 35645) |
| County: | Lauderdale |
| Place of Formation: | Lauderdale County |
| Registered Office Street Address: | 1303 HIGHWAY 72KILLEN, AL 35645 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1194216861 | 2018-05-29 | 2018-05-29 | 1303 HIGHWAY 72, KILLEN, AL, 356459136, US | 1303 HIGHWAY 72, KILLEN, AL, 356459136, US | |||||||||||||||||||||||
|
|||||||||||||||||||||||||||
| Phone | +1 256-757-5314 |
Authorized person
| Name | BRUCE EVANS |
| Role | OWNER |
| Phone | 2567668800 |
Taxonomy
| Taxonomy Code | 261QD0000X - Dental Clinic/Center |
| License Number | 3415 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 164755 |
| State | AL |
| Name | Role |
|---|---|
| EVANS, BRUCE D | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
