# EAST TENNESSEE ORAL AND MAXILLOFACIAL SURGERY, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1861701005
- **Authorized official:** DR. MARK M. WIDLOSKI DDS (OWNER)
- **Authorized official phone:** (865) 983-8630

## Contact information

- **Practice address:** 161 CAPITAL DRIVE, SUITE102, KNOXVILLE, TN 37922-3357
- **Practice address phone:** (865) 531-3909
- **Practice address fax:** (865) 539-0022
- **Mailing address:** 1505 E LAMAR ALEXANDER PKWY, MARYVILLE, TN 37804-5131
- **Mailing address phone:** (865) 983-8630
- **Mailing address fax:** (865) 981-4914

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 4711 | TN | Yes |

## Other

- **Enumeration date:** 10/06/2010
- **Last updated:** 11/29/2010