MEDICARE: STONECREST ORAL AND MAXILLOFACIAL SURGERY, INC.

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	:	1770514911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONECREST ORAL AND MAXILLOFACIAL SURGERY, INC.

Provider Business Mailing Address
First Line	:	STE 385
Second Line	:	300 STONECREST BLVD
City	:	SMYRNA
State	:	TN
Zip	:	37167-6819
Country	:	US
Telephone Number	:	615-223-1200
Fax Number	:	615-223-1090

Provider Business Practice Location Address
First Line	:	STE 385
Second Line	:	300 STONECREST BLVD
City	:	SMYRNA
State	:	TN
Zip	:	37167-6819
Country	:	US
Telephone Number	:	615-223-1200
Fax Number	:	615-223-1090

Authorized Official
Title or Position	:	ORAL & MAXILLOFACIAL SURGEON
Name	:	STONE CREST ORAL MAXILLOFA
Credential	:
Telephone Number	:	615-223-1200

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	12/05/2007

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