MEDICARE: DR. JACK SMALLEY JR. D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	AL 3757	AL

General Provider Information

NPI Number	:	1295710838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK SMALLEY JR. D.M.D

Provider Business Mailing Address
First Line	:	1100 FAIRFAX PARK
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2809
Country	:	US
Telephone Number	:	205-752-3506
Fax Number	:	205-752-3570

Provider Business Practice Location Address
First Line	:	1100 FAIRFAX PARK
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2809
Country	:	US
Telephone Number	:	205-752-3506
Fax Number	:	205-752-3570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	07/08/2007

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