Provider Demographics
NPI:1336632561
Name:GARDENDALE ORAL SURGERY, P.C.
Entity type:Organization
Organization Name:GARDENDALE ORAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-595-2131
Mailing Address - Street 1:919 SHARIT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-5008
Mailing Address - Country:US
Mailing Address - Phone:205-631-4004
Mailing Address - Fax:205-631-4007
Practice Address - Street 1:919 SHARIT AVE STE 201
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071
Practice Address - Country:US
Practice Address - Phone:205-631-4004
Practice Address - Fax:205-631-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL216971Medicaid