Provider Demographics
NPI:1073640785
Name:ALABAMA ORAL & MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:ALABAMA ORAL & MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-271-2002
Mailing Address - Street 1:4590 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2918
Mailing Address - Country:US
Mailing Address - Phone:334-271-2002
Mailing Address - Fax:334-271-4523
Practice Address - Street 1:4590 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2918
Practice Address - Country:US
Practice Address - Phone:334-271-2002
Practice Address - Fax:334-271-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG674Medicare ID - Type Unspecified