Provider Demographics
NPI:1386740140
Name:HUNTSVILLE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PC
Entity type:Organization
Organization Name:HUNTSVILLE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-534-5028
Mailing Address - Street 1:2314 PANSY ST SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3803
Mailing Address - Country:US
Mailing Address - Phone:256-534-5028
Mailing Address - Fax:256-534-5073
Practice Address - Street 1:2314 PANSY ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3803
Practice Address - Country:US
Practice Address - Phone:256-534-5028
Practice Address - Fax:256-534-5073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty