Healthcare Provider Details

I. General information

NPI: 1619162187
Provider Name (Legal Business Name): MCRAE-WILSON ORAL AND MAXILLOFACIAL SURGERY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 MURRAY RD
MEMPHIS TN
38119-3879
US

IV. Provider business mailing address

5565 MURRAY RD
MEMPHIS TN
38119-3879
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-0088
  • Fax: 901-767-2538
Mailing address:
  • Phone: 901-767-0088
  • Fax: 901-767-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3587
License Number StateTN

VIII. Authorized Official

Name: DR. JOSEPH LAWRENCE MCRAE
Title or Position: OWNER
Credential: DDS
Phone: 901-767-0088