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General NPI Number Information
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NPI Number | 1285631135
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Entity Type | Individual
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Provider Name | MARK M. WIDLOSKI DDS
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Gender | Male
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 10/10/2011
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Provider Practice Location Address
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Address Line | 1505 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-983-8630
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Fax | 865-983-3616
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Provider Business Mailing Address
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Address Line | 1505 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-983-8630
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Fax | 865-983-3616
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | DS4711
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License Number State | TN
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