Provider Demographics
NPI:1417064270
Name:ORAL AND MAXILLOFACIAL SURGERY OF EAST AL
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY OF EAST AL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-749-3436
Mailing Address - Street 1:121 N 20TH ST STE 20B
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5456
Mailing Address - Country:US
Mailing Address - Phone:334-749-3436
Mailing Address - Fax:334-749-3223
Practice Address - Street 1:121 N 20TH ST STE 20B
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5456
Practice Address - Country:US
Practice Address - Phone:334-749-3436
Practice Address - Fax:334-749-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2956CS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD665Medicare PIN