Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DS0000010524 | TN |
NPI | 1114346137 |
---|---|
Provider Name | Joseph Roman Mort |
First Address | Hendersonville, TN 37075-6207 |
Second Address | Hendersonville, TN 37075 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2014 |
Last Update Date | 15/08/2018 |