Provider Demographics
NPI:1053823005
Name:GALLOWAY DENTAL IMPLANTS AND PERIODONTICS, P.C.
Entity Type:Organization
Organization Name:GALLOWAY DENTAL IMPLANTS AND PERIODONTICS, P.C.
Other - Org Name:LEWIS G HUMPHREYS, JR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMIN ASST.
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-792-7888
Mailing Address - Street 1:102 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6902
Mailing Address - Country:US
Mailing Address - Phone:334-792-7888
Mailing Address - Fax:334-792-8717
Practice Address - Street 1:102 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6902
Practice Address - Country:US
Practice Address - Phone:334-792-7888
Practice Address - Fax:334-792-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL35951223P0300X
1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty