=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275211914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE MAXILLOFACIAL SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 07/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 ALCOA HWY STE 335
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37920-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-305-9022
-----------------------------------------------------
Fax | 865-305-9026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 ALCOA HWY STE A335
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37920-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-305-2600
-----------------------------------------------------
Fax | 865-305-2270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT TEAM LEAD
-----------------------------------------------------
Name | CAROL BURGESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-670-6754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------