1720250954 NPI number — BRIAN K SCHENCK ORAL SURGERY, PC

Table of content: (NPI 1720250954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720250954 NPI number — BRIAN K SCHENCK ORAL SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN K SCHENCK ORAL SURGERY, PC
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:
6
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:
1720250954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1446
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIXSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37343-5446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-875-4812
Provider Business Mailing Address Fax Number:
423-875-4814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4845 HIXSON PIKE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343-4466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-875-4812
Provider Business Practice Location Address Fax Number:
423-875-4814
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VARNER
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
423-875-4812

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS1883 , 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: 3215227 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com