East Tennessee Oral and Maxillofacial Surgery, PC

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

4711 Issued in TN

Legal business name

EAST TENNESSEE ORAL AND MAXILLOFACIAL SURGERY, PC

Practice address

161 Capital Drive
Suite102
Knoxville, TN 37922-3357

Phone

(865) 531-3909

Fax

(865) 539-0022

NPI assigned

Oct 6, 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

Locations

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

{
    "created_epoch": "1286323200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1290988800000",
    "number": "1861701005",
    "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": "161 CAPITAL DRIVE",
            "address_2": "SUITE102",
            "city": "KNOXVILLE",
            "state": "TN",
            "postal_code": "379223357",
            "telephone_number": "865-531-3909",
            "fax_number": "865-539-0022"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE ORAL AND MAXILLOFACIAL SURGERY, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-06",
        "last_updated": "2010-11-29",
        "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 Knoxville, TN
• Providers in Knoxville, 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 29, 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.