Healthcare Provider Details

I. General information

NPI: 1225263460
Provider Name (Legal Business Name): PROVENCE AND HALEY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4322 HARDING PIKE SUITE 201
NASHVILLE TN
37205-2490
US

IV. Provider business mailing address

4322 HARDING PIKE SUITE 201
NASHVILLE TN
37205-2490
US

V. Phone/Fax

Practice location:
  • Phone: 615-829-7000
  • Fax: 615-829-7001
Mailing address:
  • Phone: 615-829-7000
  • Fax: 615-829-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS7219
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS4607
License Number StateTN

VIII. Authorized Official

Name: MR. MINA H HARRIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 615-419-1943