Provider Demographics
NPI:1033344288
Name:PROVENCE AND HALEY, PC
Entity Type:Organization
Organization Name:PROVENCE AND HALEY, PC
Other - Org Name:TENNESSEE ORAL & MAXILLOFACIAL SURGEONS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINA
Authorized Official - Middle Name:H
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-419-1943
Mailing Address - Street 1:4322 HARDING PIKE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2490
Mailing Address - Country:US
Mailing Address - Phone:615-829-7000
Mailing Address - Fax:615-829-7001
Practice Address - Street 1:502 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2016
Practice Address - Country:US
Practice Address - Phone:615-446-9669
Practice Address - Fax:615-446-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS46071223S0112X
TNDS72191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4607OtherDENTAL LICENSE
TN2006315OtherBCBST
TN7219OtherDENTAL LICENSE
1275531972OtherNPI
1982601829OtherNPI
TN3141185OtherBCBST
667954OtherUNITED CONCORDIA
TN918666OtherUNITED CONCORDIA
TN2006315OtherBCBST
TN3141185OtherBCBST
TN3226483Medicare PIN
TN4607OtherDENTAL LICENSE