Healthcare Provider Details

I. General information

NPI: 1518130210
Provider Name (Legal Business Name): WEST TENNESSEE CENTER FOR ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 ROLAND AVE SUITE 100
JACKSON TN
38301-4379
US

IV. Provider business mailing address

544 ROLAND AVE SUITE 100
JACKSON TN
38301-4379
US

V. Phone/Fax

Practice location:
  • Phone: 731-426-1834
  • Fax: 731-426-1836
Mailing address:
  • Phone: 731-426-1834
  • Fax: 731-426-1836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD 7760
License Number StateTN

VIII. Authorized Official

Name: DR. KEITH HARRISON TAYLOR
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: D.D.S., M.P.H.
Phone: 731-426-1834