Healthcare Provider Details

I. General information

NPI: 1124295480
Provider Name (Legal Business Name): CHATTANOOGA ORAL & MAXILLOFACIAL SURGERY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 GUNBARREL RD SUITE 200
CHATTANOOGA TN
37421-3192
US

IV. Provider business mailing address

1720 GUNBARREL RD SUITE 200
CHATTANOOGA TN
37421-3192
US

V. Phone/Fax

Practice location:
  • Phone: 423-296-8905
  • Fax: 423-296-8906
Mailing address:
  • Phone: 423-296-8905
  • Fax: 423-296-8906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7277
License Number StateTN

VIII. Authorized Official

Name: DR. DAVID P MCDONALD
Title or Position: PREIDENT/ORAL SURGEON
Credential: DMD
Phone: 423-296-8905