Provider Demographics
NPI:1518130210
Name:WEST TENNESSEE CENTER FOR ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:WEST TENNESSEE CENTER FOR ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:731-426-1834
Mailing Address - Street 1:544 ROLAND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4379
Mailing Address - Country:US
Mailing Address - Phone:731-426-1834
Mailing Address - Fax:731-426-1836
Practice Address - Street 1:544 ROLAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4379
Practice Address - Country:US
Practice Address - Phone:731-426-1834
Practice Address - Fax:731-426-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND 7760261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1891795605OtherINDIVIDUAL NPI NUMBER
TN3731273OtherMEDICARE GROUP PRICING #
TNV06548Medicare UPIN