Basic Information
| Provider Information | |||||||||
| NPI: | 1629471305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORAL SURGICAL INSTITUTE, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORAL SURGERY INSTITUTE - NASHVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2014 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CRED SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2175405170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORAL SURGICAL INSTITUTE, P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.