MEDICARE: MID-STATE ORAL SURGERY OF SMYRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1407595937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-STATE ORAL SURGERY OF SMYRNA

Provider Business Mailing Address
First Line	:	445 HENSLEE DR
Second Line	:
City	:	DICKSON
State	:	TN
Zip	:	37055-2166
Country	:	US
Telephone Number	:	615-441-1441
Fax Number	:

Provider Business Practice Location Address
First Line	:	13181 OLD NASHVILLE HWY
Second Line	:
City	:	SMYRNA
State	:	TN
Zip	:	37167-4032
Country	:	US
Telephone Number	:	615-441-1441
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE
Name	:	HEATHER HIGHTOWER
Credential	:
Telephone Number	:	615-441-1441

Provider Enumeration Date	:	06/02/2022
Last Update Date	:	06/02/2022

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