Healthcare Provider Details

I. General information

NPI: 1992976997
Provider Name (Legal Business Name): CENTER FOR ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 WESLEY DR SUITE 101
MEMPHIS TN
38116-6442
US

IV. Provider business mailing address

1251 WESLEY DR SUITE 101
MEMPHIS TN
38116-6442
US

V. Phone/Fax

Practice location:
  • Phone: 901-398-0793
  • Fax: 901-398-0222
Mailing address:
  • Phone: 901-398-0793
  • Fax: 901-398-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. JESSICA R. FORTNER
Title or Position: ADMINISTRATIVE ASSISSTANT
Credential:
Phone: 901-398-0793