Provider Demographics
NPI:1700970407
Name:PROFESSIONAL MEDICAL PROPERTIES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL PROPERTIES, LLC
Other - Org Name:CENTER FOR ORAL FACIAL AND IMPLANT SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:TIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-893-3333
Mailing Address - Street 1:6015 SHALLOWFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1688
Mailing Address - Country:US
Mailing Address - Phone:423-893-3333
Mailing Address - Fax:423-954-3054
Practice Address - Street 1:6015 SHALLOWFORD ROAD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1688
Practice Address - Country:US
Practice Address - Phone:423-954-9180
Practice Address - Fax:423-954-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1224261QS0112X
261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3287837Medicaid
TN3287837Medicaid