Provider Demographics
NPI:1952547366
Name:SOUTHEAST ORAL SURGERY PC
Entity Type:Organization
Organization Name:SOUTHEAST ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-977-7110
Mailing Address - Street 1:1858 CREST RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-4305
Mailing Address - Country:US
Mailing Address - Phone:865-977-7110
Mailing Address - Fax:865-977-4132
Practice Address - Street 1:801 W OLDHAM AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-2747
Practice Address - Country:US
Practice Address - Phone:865-522-1244
Practice Address - Fax:865-525-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty