Healthcare Provider Details

I. General information

NPI: 1568985349
Provider Name (Legal Business Name): EASTERN SHORE ORAL, FACIAL AND IMPLANT SURGERY CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24172 4TH STREET
FAIRHOPE AL
36532
US

IV. Provider business mailing address

24172 4TH STREET
FAIRHOPE AL
36532
US

V. Phone/Fax

Practice location:
  • Phone: 251-333-1700
  • Fax: 251-333-1701
Mailing address:
  • Phone: 251-333-1700
  • Fax: 251-333-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number6357
License Number StateAL

VIII. Authorized Official

Name: RICHARD CORDERO
Title or Position: OWNER/ SURGEON
Credential: DMD, MD
Phone: 251-333-1700