Provider Demographics
NPI:1730407560
Name:PLATEAU ORAL SURGERY, PC
Entity type:Organization
Organization Name:PLATEAU ORAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-525-6059
Mailing Address - Street 1:920 SOUTH WILLOW AVENUE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4150
Mailing Address - Country:US
Mailing Address - Phone:931-525-6059
Mailing Address - Fax:931-525-6079
Practice Address - Street 1:920 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4150
Practice Address - Country:US
Practice Address - Phone:931-525-6059
Practice Address - Fax:931-525-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND57545261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226373Medicaid
TN3226373Medicaid