=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225263460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVENCE AND HALEY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2009
-----------------------------------------------------
Last Update Date | 05/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4322 HARDING PIKE SUITE 201
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37205-2490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-829-7000
-----------------------------------------------------
Fax | 615-829-7001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4322 HARDING PIKE SUITE 201
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37205-2490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-829-7000
-----------------------------------------------------
Fax | 615-829-7001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. MINA H HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-419-1943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DS7219
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DS4607
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------