Provider Demographics
NPI:1598746927
Name:KNOXVILLE ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:KNOXVILLE ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-584-6207
Mailing Address - Street 1:6207 HIGHLAND PLACE WAY
Mailing Address - Street 2:STE 207
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4027
Mailing Address - Country:US
Mailing Address - Phone:865-584-6207
Mailing Address - Fax:865-934-0080
Practice Address - Street 1:6207 HIGHLAND PLACE WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4027
Practice Address - Country:US
Practice Address - Phone:865-584-6207
Practice Address - Fax:865-934-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4447359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
400149OtherBLUE CROSS
5315104OtherAETNA
T74434Medicare UPIN
3225414Medicare ID - Type Unspecified