Provider Demographics
NPI:1073748042
Name:CLARKSVILLE ORAL AND FACIAL SURGERY, PLLC
Entity Type:Organization
Organization Name:CLARKSVILLE ORAL AND FACIAL SURGERY, PLLC
Other - Org Name:CLARKSVILLE ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:931-552-7575
Mailing Address - Street 1:1718 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4542
Mailing Address - Country:US
Mailing Address - Phone:931-552-4935
Mailing Address - Fax:931-552-0959
Practice Address - Street 1:1718 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4542
Practice Address - Country:US
Practice Address - Phone:931-552-4935
Practice Address - Fax:931-552-0959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty