=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184733446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST ORAL SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 04/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1858 CREST RD
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-977-7110
-----------------------------------------------------
Fax | 865-977-4132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1858 CREST RD
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-977-7110
-----------------------------------------------------
Fax | 865-977-4132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TIMOTHY P MCCONNELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 865-977-7110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------