Provider Demographics
NPI:1215032438
Name:DICKSON JAW & FACIAL SURGERY
Entity Type:Organization
Organization Name:DICKSON JAW & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-441-1441
Mailing Address - Street 1:445 HENSLEE DR
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2166
Mailing Address - Country:US
Mailing Address - Phone:615-441-1441
Mailing Address - Fax:615-441-1460
Practice Address - Street 1:445 HENSLEE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2166
Practice Address - Country:US
Practice Address - Phone:615-441-1441
Practice Address - Fax:615-441-1460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000079151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734371Medicare PIN