Provider Demographics
NPI:1649707514
Name:MINTO ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:MINTO ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:MINTO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:251-990-5959
Mailing Address - Street 1:19748 GREENO RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19748 GREENO RD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3836
Practice Address - Country:US
Practice Address - Phone:251-990-5959
Practice Address - Fax:521-378-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL63811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty