1992976997 NPI number — CENTER FOR ORAL AND FACIAL SURGERY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992976997 NPI number — CENTER FOR ORAL AND FACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR ORAL AND FACIAL SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992976997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1251 WESLEY DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38116-6442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-398-0793
Provider Business Mailing Address Fax Number:
901-398-0222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 WESLEY DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38116-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-398-0793
Provider Business Practice Location Address Fax Number:
901-398-0222
Provider Enumeration Date:
03/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FORTNER
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
ADMINISTRATIVE ASSISSTANT
Authorized Official Telephone Number:
901-398-0793

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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