East Tennessee Oral & Maxillofacial Surgery, PC

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

4711 Issued in TN

Legal business name

EAST TENNESSEE ORAL & MAXILLOFACIAL SURGERY, PC

Practice address

2253 Chambliss Ave NW
Suite 403
Cleveland, TN 37311-3861

Phone

(423) 709-0400

Fax

(423) 709-0401

NPI assigned

Oct 12, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Mark M Widloski, DDS

Title

Owner

Phone

(865) 983-8630

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1286841600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1290038400000",
    "number": "1497065494",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1505 E LAMAR ALEXANDER PKWY",
            "city": "MARYVILLE",
            "state": "TN",
            "postal_code": "378045131",
            "telephone_number": "865-983-8630",
            "fax_number": "865-981-4914"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2253 CHAMBLISS AVE NW",
            "address_2": "SUITE 403",
            "city": "CLEVELAND",
            "state": "TN",
            "postal_code": "373113861",
            "telephone_number": "423-709-0400",
            "fax_number": "423-709-0401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE ORAL & MAXILLOFACIAL SURGERY, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-12",
        "last_updated": "2010-11-18",
        "status": "A",
        "authorized_official_last_name": "WIDLOSKI",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "865-983-8630",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "TN",
            "license": "4711",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Oral and Maxillofacial Surgery (Dentist) in Cleveland, TN
• Providers in Cleveland, TN by specialty
• Oral and Maxillofacial Surgery (Dentist) in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.