Provider Demographics
NPI:1003099227
Name:TRI-STATE ORAL AND MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:TRI-STATE ORAL AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:STIGALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-586-4825
Mailing Address - Street 1:2300 CONNER RD
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:KY
Mailing Address - Zip Code:41048
Mailing Address - Country:US
Mailing Address - Phone:859-586-4825
Mailing Address - Fax:859-586-4817
Practice Address - Street 1:2300 CONNER RD
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:KY
Practice Address - Zip Code:41048
Practice Address - Country:US
Practice Address - Phone:859-586-4825
Practice Address - Fax:859-586-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY803261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery