Provider Demographics
NPI:1700243102
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:OWNER
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 1:515 STONECREST PKWY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6826
Mailing Address - Country:US
Mailing Address - Phone:615-462-7987
Mailing Address - Fax:615-625-3405
Practice Address - Street 1:515 STONECREST PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6826
Practice Address - Country:US
Practice Address - Phone:615-462-7987
Practice Address - Fax:615-625-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN72481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty