Provider Demographics
NPI:1497843270
Name:MIDDLE TENNESSEE ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:MIDDLE TENNESSEE ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-893-7736
Mailing Address - Street 1:1725 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2246
Mailing Address - Country:US
Mailing Address - Phone:615-893-7736
Mailing Address - Fax:615-898-1771
Practice Address - Street 1:1725 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2246
Practice Address - Country:US
Practice Address - Phone:615-893-7736
Practice Address - Fax:615-898-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS72481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226896Medicare ID - Type Unspecified