Provider Demographics
NPI:1235213869
Name:REGIONAL ORAL SURGERY CENTER PC
Entity Type:Organization
Organization Name:REGIONAL ORAL SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROOKSBANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-528-6252
Mailing Address - Street 1:33 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2513
Mailing Address - Country:US
Mailing Address - Phone:931-528-6252
Mailing Address - Fax:931-372-8526
Practice Address - Street 1:33 W 3RD ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2513
Practice Address - Country:US
Practice Address - Phone:931-528-6252
Practice Address - Fax:931-372-8526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226337Medicaid
TN3226337Medicaid