Healthcare Provider Details

I. General information

NPI: 1225348220
Provider Name (Legal Business Name): EAST TENNESSEE ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 ESSARY RD SUITE 1
KNOXVILLE TN
37918-2464
US

IV. Provider business mailing address

1505 E LAMAR ALEXANDER PKWY
MARYVILLE TN
37804-5131
US

V. Phone/Fax

Practice location:
  • Phone: 865-688-0410
  • Fax: 865-688-8728
Mailing address:
  • Phone: 865-983-8630
  • Fax: 865-981-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4711
License Number StateTN

VIII. Authorized Official

Name: DR. MARK M WIDLOSKI
Title or Position: OWNER
Credential: DDS
Phone: 865-983-8630