Healthcare Provider Details

I. General information

NPI: 1043940265
Provider Name (Legal Business Name): JESSE WILLIAM AUSTIN III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 HALCYON SUMMIT DR
MONTGOMERY AL
36117-7047
US

IV. Provider business mailing address

7814 EBURY ST
MONTGOMERY AL
36116-6774
US

V. Phone/Fax

Practice location:
  • Phone: 334-277-3492
  • Fax: 334-277-9432
Mailing address:
  • Phone: 334-430-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD.007609-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: