Organization
GARDENDALE ORAL SURGERY, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JUSTIN D LACKEY (FRONT OFFICE)
(256) 595-2131
Entity
Organization
Contact information
Practice address
919 SHARIT AVE STE 201, GARDENDALE, AL 35071
(205) 631-4004
(205) 631-4007
Mailing address
919 SHARIT AVE STE 201, GARDENDALE, AL 35071-5008
(205) 631-4004
(205) 631-4007
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
216971
—
AL
Enumeration date
06/12/2018
Last updated
07/05/2018
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