Healthcare Provider Details

I. General information

NPI: 1023289998
Provider Name (Legal Business Name): METRO ORAL & MAXILLOFACIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 METRO DR
DOTHAN AL
36303-1985
US

IV. Provider business mailing address

100 METRO DR
DOTHAN AL
36303-1985
US

V. Phone/Fax

Practice location:
  • Phone: 334-699-5555
  • Fax:
Mailing address:
  • Phone: 334-699-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number5391C
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number5391C
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5391C
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier755031
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerUNITED CONCORDIA
# 2
Identifier51529237
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBCBS OF ALABAMA
# 3
Identifier5391C
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerALABAMA LICENSE #

VIII. Authorized Official

Name: DR. CRAIG D SCHMIDTKE
Title or Position: ORAL SURGEON/OWNER
Credential: DDS
Phone: 334-699-5555