Provider Demographics
NPI:1679671986
Name:SOUTHERN ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:SOUTHERN ORAL AND FACIAL SURGERY
Other - Org Name:CLARK ORAL AND FACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:615-591-0919
Mailing Address - Street 1:3000 STANSBERRY LANE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37069
Mailing Address - Country:US
Mailing Address - Phone:615-591-0919
Mailing Address - Fax:615-599-6762
Practice Address - Street 1:3000 STANSBERRY LANE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37069
Practice Address - Country:US
Practice Address - Phone:615-591-0919
Practice Address - Fax:615-599-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty