Healthcare Provider Details

I. General information

NPI: 1275211914
Provider Name (Legal Business Name): TENNESSEE MAXILLOFACIAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/26/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 ALCOA HWY STE 335
KNOXVILLE TN
37920-1585
US

IV. Provider business mailing address

1930 ALCOA HWY STE A335
KNOXVILLE TN
37920-1585
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-9022
  • Fax: 865-305-9026
Mailing address:
  • Phone: 865-305-2600
  • Fax: 865-305-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: CAROL BURGESS
Title or Position: PROVIDER ENROLLMENT TEAM LEAD
Credential:
Phone: 865-670-6754