Provider Demographics
NPI:1083800668
Name:MICHAEL L BOBO, DDS, MD, PSC
Entity Type:Organization
Organization Name:MICHAEL L BOBO, DDS, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOBO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MD,FACS
Authorized Official - Phone:731-885-7891
Mailing Address - Street 1:1320 PLEASANT VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5958
Mailing Address - Country:US
Mailing Address - Phone:731-885-7891
Mailing Address - Fax:731-885-7894
Practice Address - Street 1:1320 PLEASANT VALLEY AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5958
Practice Address - Country:US
Practice Address - Phone:731-885-7891
Practice Address - Fax:731-885-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN74041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3873274Medicare PIN