MEDICARE: ORAL & MAXILLOFACIAL SURGERY ASSOC PC

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	DS02991	TN
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	DS04769	TN

General Provider Information

NPI Number	:	1538327655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORAL & MAXILLOFACIAL SURGERY ASSOC PC

Provider Business Mailing Address
First Line	:	11213 W POINT DR STE 501
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37934-2838
Country	:	US
Telephone Number	:	865-675-0677
Fax Number	:	865-675-0681

Provider Business Practice Location Address
First Line	:	11213 W POINT DR STE 501
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37934-2838
Country	:	US
Telephone Number	:	865-675-0677
Fax Number	:	865-675-0681

Authorized Official
Title or Position	:	ORAL SURGEON VICE PRESIDENT
Name	:	THEODORE 'TED' A GEORGE JR.
Credential	:	DDS
Telephone Number	:	865-675-0677

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/29/2019

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