MEDICARE: EAST TN FACIAL SURGERY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DS0000004615	TN

General Provider Information

NPI Number	:	1679543912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TN FACIAL SURGERY, INC

Provider Business Mailing Address
First Line	:	625 MORRISON SPRINGS RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-3401
Country	:	US
Telephone Number	:	423-855-5550
Fax Number	:	423-899-9182

Provider Business Practice Location Address
First Line	:	625 MORRISON SPRINGS RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-3401
Country	:	US
Telephone Number	:	423-855-5550
Fax Number	:	423-899-9182

Authorized Official
Title or Position	:	ORAL & MAXILLOFACIAL SURGEON
Name	:	DR. THOMAS R COOK III
Credential	:	DMD, MD
Telephone Number	:	423-855-5550

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	08/22/2020

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