Healthcare Provider Details

I. General information

NPI: 1376271056
Provider Name (Legal Business Name): MANISCALCO ORAL AND FACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HEATHERBROOKE PARK DR
BIRMINGHAM AL
35242-8008
US

IV. Provider business mailing address

101 HEATHERBROOKE PARK DR
BIRMINGHAM AL
35242-8008
US

V. Phone/Fax

Practice location:
  • Phone: 205-991-9787
  • Fax:
Mailing address:
  • Phone: 205-991-9787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEE MICHAEL MANISCALCO
Title or Position: OWNER
Credential: MD, DMD
Phone: 205-527-3091