Provider Demographics
NPI:1093077166
Name:KY TN ORAL SURGERY PLLC
Entity Type:Organization
Organization Name:KY TN ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/ MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BOBO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:270-759-4063
Mailing Address - Street 1:1109 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2360
Mailing Address - Country:US
Mailing Address - Phone:270-759-4063
Mailing Address - Fax:270-759-4920
Practice Address - Street 1:1109 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2360
Practice Address - Country:US
Practice Address - Phone:270-759-4063
Practice Address - Fax:270-759-4920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74651223S0112X
KY88411223S0112X, 204E00000X
TN74041223S0112X
TN83341223S0112X, 204E00000X
KY34759204E00000X
TN30866204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty