| NPI | 1275211914 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CAROL BURGESS Provider Enrollment Team Lead 865-670-6754 |
| Organization Subpart ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery |
| Enumeration Date | 2023-07-11 |
| Last Update Date | 2025-07-26 |