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General NPI Number Information
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NPI Number | 1215032438
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Entity Type | Organization
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Legal Business Name | DICKSON JAW & FACIAL SURGERY
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 06/23/2009
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Provider Practice Location Address
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Address Line | 445 HENSLEE DR
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City | DICKSON
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State | TN
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Zip | 37055-2166
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Country | US
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Telephone | 615-441-1441
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Fax | 615-441-1460
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Provider Business Mailing Address
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Address Line | 445 HENSLEE DR
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City | DICKSON
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State | TN
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Zip | 37055-2166
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Country | US
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Telephone | 615-441-1441
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Fax | 615-441-1460
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. LORI ANN PETTY
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Credential |
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Telephone | 615-441-1441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DS0000007915
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License Number State | TN
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