Healthcare Provider Details

I. General information

NPI: 1346576915
Provider Name (Legal Business Name): MADISON ORAL AND FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 HUGHES RD SUITE 1500
MADISON AL
35758-2237
US

IV. Provider business mailing address

44 HUGHES RD SUITE 1500
MADISON AL
35758-2237
US

V. Phone/Fax

Practice location:
  • Phone: 256-774-3535
  • Fax:
Mailing address:
  • Phone: 256-774-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5551
License Number StateAL

VIII. Authorized Official

Name: DR. RAKESH SHAH
Title or Position: MANAGING MEMBER
Credential: MD, DMD
Phone: 205-572-5880