Healthcare Provider Details

I. General information

NPI: 1427163666
Provider Name (Legal Business Name): THE REGIONAL CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W OAKLAND AVE SUITE 109
JOHNSON CITY TN
37604-2191
US

IV. Provider business mailing address

1021 W OAKLAND AVE SUITE 109
JOHNSON CITY TN
37604-2191
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-4555
  • Fax: 423-283-3044
Mailing address:
  • Phone: 423-283-4555
  • Fax: 423-283-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS004426
License Number StateTN

VIII. Authorized Official

Name: DR. CHARLES EDWARD WITKOWSKI
Title or Position: OWNER
Credential: DDS
Phone: 423-283-4555