Provider Demographics
NPI:1225543515
Name:ORAL & FACIAL SURGERY OF EAST ALABAMA, LLC
Entity Type:Organization
Organization Name:ORAL & FACIAL SURGERY OF EAST ALABAMA, LLC
Other - Org Name:ORAL & FACIAL SURGERY OF WEST GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:334-749-3436
Mailing Address - Street 1:747 N DEAN ROAD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830
Mailing Address - Country:US
Mailing Address - Phone:334-749-3436
Mailing Address - Fax:334-749-3233
Practice Address - Street 1:4405 N STADIUM DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:334-749-3436
Practice Address - Fax:334-749-3233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORAL & FACIAL SURGERY OF EAST ALABAMA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD285331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003194410AMedicaid