| Organization Name: | TRI-STATE ORAL AND MAXILLOFACIAL SURGERY LLC |
| NPI Number: | 1003099227 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RODNEY CHRISTOPHER STIGALL (MEMBER) |
| Mailing Address: | 2300 Conner Rd Hebron |
| State: | KY US |
| Postal Code: | 41048 |
| Phone Number: | 8595864825 |
| Fax Number: | 8595864817 |
| NPI Enumeration Date: | 12/11/2007 |
| NPI Last Update Date: | 12/11/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QS0112X |
| License Number: | 803 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Oral and Maxillofacial Surgery |
| Taxonomy Definition: | The specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region. |