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General NPI Number Information
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NPI Number | 1336632561
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Entity Type | Organization
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Legal Business Name | GARDENDALE ORAL SURGERY, P.C.
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Dates
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Enumeration Date | 06/12/2018
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Last Update Date | 07/05/2018
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Provider Practice Location Address
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Address Line | 919 SHARIT AVE STE 201
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City | GARDENDALE
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State | AL
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Zip | 35071
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Country | US
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Telephone | 205-631-4004
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Fax | 205-631-4007
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Provider Business Mailing Address
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Address Line | 919 SHARIT AVE STE 201
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City | GARDENDALE
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State | AL
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Zip | 35071-5008
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Country | US
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Telephone | 205-631-4004
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Fax | 205-631-4007
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Authorized Official
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Title or Position | FRONT OFFICE
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Name | JUSTIN D LACKEY
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Credential |
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Telephone | 256-595-2131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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