Healthcare Provider Details

I. General information

NPI: 1063457919
Provider Name (Legal Business Name): BAY AREA ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 GRELOT RD BUILDING C
MOBILE AL
36609-3603
US

IV. Provider business mailing address

5901 GRELOT RD BUILDING C
MOBILE AL
36609-3603
US

V. Phone/Fax

Practice location:
  • Phone: 251-344-6191
  • Fax: 251-344-6794
Mailing address:
  • Phone: 251-344-6191
  • Fax: 251-344-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4598
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number5437
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3814
License Number StateAL

VIII. Authorized Official

Name: MS. JEANNE MARZULLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 251-344-6191