1861701005 NPI number — EAST TENNESSEE ORAL AND MAXILLOFACIAL SURGERY, PC

Table of content: (NPI 1861701005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861701005 NPI number — EAST TENNESSEE ORAL AND MAXILLOFACIAL SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE ORAL AND MAXILLOFACIAL 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:
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:
1861701005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 E LAMAR ALEXANDER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37804-5131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-983-8630
Provider Business Mailing Address Fax Number:
865-981-4914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 CAPITAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE102
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-531-3909
Provider Business Practice Location Address Fax Number:
865-539-0022
Provider Enumeration Date:
10/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WIDLOSKI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-983-8630

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  4711 , 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)





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