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General NPI Number Information
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NPI Number | 1154589216
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Entity Type | Organization
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Legal Business Name | TRI-STATE ORAL & FACIAL SURGERY
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Dates
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Enumeration Date | 05/27/2008
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Last Update Date | 05/27/2008
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Provider Practice Location Address
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Address Line | 2844 CARTER AVE
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City | ASHLAND
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State | KY
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Zip | 41101-1917
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Country | US
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Telephone | 606-329-1115
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Fax |
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Provider Business Mailing Address
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Address Line | 2844 CARTER AVE
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City | ASHLAND
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State | KY
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Zip | 41101-1917
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Country | US
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Telephone | 606-329-1115
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL D. COURCHO
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Credential | DMD, MD
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Telephone | 606-329-1115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 34851
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License Number State | KY
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