Provider Demographics
NPI:1538327655
Name:ORAL & MAXILLOFACIAL SURGERY ASSOC PC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE 'TED'
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-675-0677
Mailing Address - Street 1:11213 W POINT DR STE 501
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2838
Mailing Address - Country:US
Mailing Address - Phone:865-675-0677
Mailing Address - Fax:865-675-0681
Practice Address - Street 1:11213 W POINT DR STE 501
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2838
Practice Address - Country:US
Practice Address - Phone:865-675-0677
Practice Address - Fax:865-675-0681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS04769204E00000X
TNDS02991204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3223817Medicare PIN
TN3225683Medicare PIN
TNT98032Medicare UPIN
TN3223817Medicare Oscar/Certification
TNT74293Medicare UPIN
TN3225683Medicare Oscar/Certification