1518130210 NPI number — WEST TENNESSEE CENTER FOR ORAL AND FACIAL SURGERY

Table of content: (NPI 1518130210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518130210 NPI number — WEST TENNESSEE CENTER FOR ORAL AND FACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST TENNESSEE 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:
1518130210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
544 ROLAND AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38301-4379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-426-1834
Provider Business Mailing Address Fax Number:
731-426-1836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
544 ROLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38301-4379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-426-1834
Provider Business Practice Location Address Fax Number:
731-426-1836
Provider Enumeration Date:
04/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
HARRISON
Authorized Official Title or Position:
ORAL AND MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
731-426-1834

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  D 7760 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1891795605 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3731273 . This is a "MEDICARE GROUP PRICING #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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