Healthcare Provider Details

I. General information

NPI: 1396121000
Provider Name (Legal Business Name): PLATEAU ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S WILLOW AVE
COOKEVILLE TN
38501-4150
US

IV. Provider business mailing address

920 S WILLOW AVE
COOKEVILLE TN
38501-4150
US

V. Phone/Fax

Practice location:
  • Phone: 931-525-6059
  • Fax: 931-525-6099
Mailing address:
  • Phone: 931-525-6059
  • Fax: 931-525-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9568
License Number StateTN

VIII. Authorized Official

Name: DR. CORTLAND CALDEMEYER
Title or Position: OWNER
Credential: DDS
Phone: 931-525-6059