Healthcare Provider Details

I. General information

NPI: 1528101698
Provider Name (Legal Business Name): LEROY A KAMELCHUK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 GLENEAGLES DR SW
HUNTSVILLE AL
35801-6405
US

IV. Provider business mailing address

1107 GLENEAGLES DR SW
HUNTSVILLE AL
35801-6405
US

V. Phone/Fax

Practice location:
  • Phone: 256-882-3312
  • Fax: 256-882-9472
Mailing address:
  • Phone: 256-882-3312
  • Fax: 256-882-9472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4438
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number20060
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: