Organization
PROVENCE AND HALEY, PC
Active
Other names
Tennessee Oral & Maxillofacial Surgeons
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MINA H HARRIS (OFFICE MANAGER)
(615) 419-1943
Entity
Organization
Contact information
Practice address
4322 HARDING PIKE, SUITE 201, NASHVILLE, TN 37205-2490
(615) 829-7000
(615) 829-7001
Mailing address
4322 HARDING PIKE, SUITE 201, NASHVILLE, TN 37205-2490
(615) 829-7000
(615) 829-7001
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
DS4607
TN
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DS7219
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1275531972
NPI
—
01
—
1982601829
NPI
—
01
—
2006315
BCBST
TN
01
—
3141185
BCBST
TN
01
—
4607
DENTAL LICENSE
TN
01
—
667954
UNITED CONCORDIA
—
01
—
7219
DENTAL LICENSE
TN
01
—
918666
UNITED CONCORDIA
—
Enumeration date
05/18/2009
Last updated
05/18/2009
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