Healthcare Provider Details

I. General information

NPI: 1770514911
Provider Name (Legal Business Name): STONECREST ORAL AND MAXILLOFACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STE 385 300 STONECREST BLVD
SMYRNA TN
37167-6819
US

IV. Provider business mailing address

STE 385 300 STONECREST BLVD
SMYRNA TN
37167-6819
US

V. Phone/Fax

Practice location:
  • Phone: 615-223-1200
  • Fax: 615-223-1090
Mailing address:
  • Phone: 615-223-1200
  • Fax: 615-223-1090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STONE CREST ORAL MAXILLOFA
Title or Position: ORAL & MAXILLOFACIAL SURGEON
Credential:
Phone: 615-223-1200