Healthcare Provider Details

I. General information

NPI: 1225543515
Provider Name (Legal Business Name): ORAL & FACIAL SURGERY OF EAST ALABAMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 N STADIUM DRIVE SUITE A
COLUMBUS GA
31909
US

IV. Provider business mailing address

747 N DEAN ROAD
AUBURN AL
36830
US

V. Phone/Fax

Practice location:
  • Phone: 334-749-3436
  • Fax: 334-749-3233
Mailing address:
  • Phone: 334-749-3436
  • Fax: 334-749-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberMD28533
License Number StateAL

VIII. Authorized Official

Name: THOMAS H FUQUA
Title or Position: MANAGING MEMBER
Credential: DMD, MD
Phone: 334-749-3436