# GARDENDALE ORAL SURGERY, P.C.

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336632561
- **Authorized official:** JUSTIN D LACKEY (FRONT OFFICE)
- **Authorized official phone:** (256) 595-2131

## Contact information

- **Practice address:** 919 SHARIT AVE STE 201, GARDENDALE, AL 35071
- **Practice address phone:** (205) 631-4004
- **Practice address fax:** (205) 631-4007
- **Mailing address:** 919 SHARIT AVE STE 201, GARDENDALE, AL 35071-5008
- **Mailing address phone:** (205) 631-4004
- **Mailing address fax:** (205) 631-4007

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 06/12/2018
- **Last updated:** 07/05/2018