Healthcare Provider Details

I. General information

NPI: 1679671986
Provider Name (Legal Business Name): SOUTHERN ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 STANSBERRY LANE SUITE 101
FRANKLIN TN
37069
US

IV. Provider business mailing address

3000 STANSBERRY LANE SUITE 101
FRANKLIN TN
37069
US

V. Phone/Fax

Practice location:
  • Phone: 615-591-0919
  • Fax: 615-599-6762
Mailing address:
  • Phone: 615-591-0919
  • Fax: 615-599-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8111
License Number StateTN

VIII. Authorized Official

Name: DR. HOWARD DANIEL CLARK
Title or Position: MANAGING PARTNER
Credential: DDS, MD
Phone: 615-591-0919