MEDICARE: DR. HARRY RUSSELL MACK JR. DDS,MD

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4873	TN

General Provider Information

NPI Number	:	1639263783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY RUSSELL MACK JR. DDS,MD

Provider Business Mailing Address
First Line	:	5802 NOLENSVILLE PIKE
Second Line	:	SUITE #103
City	:	NASHVILLE
State	:	TN
Zip	:	37211-6520
Country	:	US
Telephone Number	:	615-873-4495
Fax Number	:	615-873-4436

Provider Business Practice Location Address
First Line	:	5802 NOLENSVILLE PIKE
Second Line	:	SUITE #103
City	:	NASHVILLE
State	:	TN
Zip	:	37211-6520
Country	:	US
Telephone Number	:	615-873-4495
Fax Number	:	615-873-4436

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	05/28/2014

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