| Name: | Gardendale Oral Surgery, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Dissolved |
| Date of registration: | 12 Jun 2018 (6 years ago) |
| Date of dissolution: | 27 Dec 2019 |
| Entity Number: | 000-521-233 |
| Register Number: | 000521233 |
| County: | Jefferson |
| Place of Formation: | Jefferson County |
| Principal Address: | 919 SHARIT AVENUE SUITE 201GARDENDALE, AL 35071 |
| Principal Address ZIP Code: | 35071 |
| Authorized Capital: | 1000@$1.00PV |
Activities
PROFESSIONAL SERVICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1336632561 | 2018-06-12 | 2018-07-05 | 919 SHARIT AVE STE 201, GARDENDALE, AL, 350715008, US | 919 SHARIT AVE STE 201, GARDENDALE, AL, 35071, US | |||||||||||||||||||||
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| Phone | +1 205-631-4004 |
| Fax | 2056314007 |
Authorized person
| Name | JUSTIN D LACKEY |
| Role | FRONT OFFICE |
| Phone | 2565952131 |
Taxonomy
| Taxonomy Code | 1223S0112X - Oral and Maxillofacial Surgery (Dentist) |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 216971 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| ROBSON, HENRY P | Agent | 919 SHARIT AVENUE SUITE 201GARDENDALE, AL 35071 |
| Name | Role | Address |
|---|---|---|
| ROBSON, HENRY P | Director | 919 SHARIT AVENUE SUITE 201GARDENDALE, AL 35071 |
| Name | Role | Address |
|---|---|---|
| ROBSON, HENRY P | Incorporator | 919 SHARIT AVENUE SUITE 201GARDENDALE, AL 35071 |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
