Healthcare Provider Details

I. General information

NPI: 1730407560
Provider Name (Legal Business Name): PLATEAU ORAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 06/20/2018
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 SOUTH WILLOW AVENUE
COOKEVILLE TN
38501-4150
US

V. Phone/Fax

Practice location:
  • Phone: 931-525-6059
  • Fax: 931-525-6079
Mailing address:
  • Phone: 931-525-6059
  • Fax: 931-525-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD57545
License Number StateTN

VIII. Authorized Official

Name: MRS. NANCY J KELLY
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 931-525-6059