Provider Demographics
NPI:1992976997
Name:CENTER FOR ORAL AND FACIAL SURGERY
Entity type:Organization
Organization Name:CENTER FOR ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISSTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-398-0793
Mailing Address - Street 1:1251 WESLEY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6442
Mailing Address - Country:US
Mailing Address - Phone:901-398-0793
Mailing Address - Fax:901-398-0222
Practice Address - Street 1:1251 WESLEY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6442
Practice Address - Country:US
Practice Address - Phone:901-398-0793
Practice Address - Fax:901-398-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty