Provider Demographics
NPI:1427163666
Name:THE REGIONAL CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:THE REGIONAL CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WITKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-283-4555
Mailing Address - Street 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-283-4555
Mailing Address - Fax:423-283-3044
Practice Address - Street 1:1021 W OAKLAND AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2191
Practice Address - Country:US
Practice Address - Phone:423-283-4555
Practice Address - Fax:423-283-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0044261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID
TNT74435Medicare UPIN
TN3225406Medicare ID - Type Unspecified