Basic Information
| Provider Information | |||||||||
| NPI: | 1023383874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORAL FACIAL SURGERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 322 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 322 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6153294401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000014 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3630981 | 05 | TN | MEDICAID |