Provider Demographics
NPI:1770776155
Name:ORAL AND FACIAL SURGERY CENTER OF TALLAHASSEE
Entity type:Organization
Organization Name:ORAL AND FACIAL SURGERY CENTER OF TALLAHASSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRETT
Authorized Official - Middle Name:R
Authorized Official - Last Name:TOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-386-4602
Mailing Address - Street 1:3330 CAPITAL OAKS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4513
Mailing Address - Country:US
Mailing Address - Phone:850-386-4602
Mailing Address - Fax:850-386-4206
Practice Address - Street 1:3375 CAPITAL CIR NE BLDG D
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-3778
Practice Address - Country:US
Practice Address - Phone:850-386-4602
Practice Address - Fax:850-386-4206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN174621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076811100Medicaid
FL87451OtherBLUE CROSS BLUE SHIELD
FL076811100Medicaid