Provider Demographics
NPI:1578634515
Name:UNIVIVERSITY ORAL AND FACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:UNIVIVERSITY ORAL AND FACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:MCILWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-556-2323
Mailing Address - Street 1:651 HELEN KELLER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-2983
Mailing Address - Country:US
Mailing Address - Phone:205-556-2323
Mailing Address - Fax:205-556-2341
Practice Address - Street 1:651 HELEN KELLER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-2983
Practice Address - Country:US
Practice Address - Phone:205-556-2323
Practice Address - Fax:205-556-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD223Medicare PIN