Healthcare Provider Details

I. General information

NPI: 1720417280
Provider Name (Legal Business Name): KINGRY ORTHODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 SEATON PL SUITE A
MONTGOMERY AL
36116-7205
US

IV. Provider business mailing address

8101 SEATON PL SUITE A
MONTGOMERY AL
36116-7205
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-4900
  • Fax: 334-409-9933
Mailing address:
  • Phone: 334-272-4900
  • Fax: 334-409-9933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4440
License Number StateAL

VIII. Authorized Official

Name: DR. GIPSON MARK KINGRY
Title or Position: ORTHODONTIST
Credential: D.M.D.
Phone: 334-272-4900