DENTAL PRACTICE GROUP OF TENNESSEE (JACKSON FAMILY DENTAL CARE) - NPI NUMBER 1013265586

Summary

Provider Name: DENTAL PRACTICE GROUP OF TENNESSEE (JACKSON FAMILY DENTAL CARE)

NPI Number: 1013265586

Clasification: Durable Medical Equipment & Medical Supplies (332BC3200X)

Specialization: Customized Equipment

Address:
78 LYNOAK CV
JACKSON, TN
ZIP 38305

Phone Number: (731) 668-2795



Detailed Information

DENTAL PRACTICE GROUP OF TENNESSEE is a customized equipment durable medical equipment & medical supplies in Jackson, TN. The assigned NPI number for this provider is 1013265586 and is registered as an organization entity type.
The provider Is Doing Business As Jackson Family Dental Care.

The provider's business address is:

78 LYNOAK CV
JACKSON, TN
ZIP 38305-800
Phone: (731) 668-2795
Fax: (731) 668-1012

The provider's authorized official is Todd Christie .
The authorized official title is Ceo and has the following contact phone number (321) 800-3771.

The enumeration date for this NPI number is 8/15/2012 and was last updated on 8/16/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment 3105 TN Yes

NPI Record

No. Field Name Field Value
1 NPI 1013265586
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name DENTAL PRACTICE GROUP OF TENNESSEE
5 Provider Other Organization Name JACKSON FAMILY DENTAL CARE
6 Provider Other Organization Name Type Code 3
7 Provider First Line Business Practice Location Address 78 LYNOAK CV
8 Provider Business Practice Location Address City Name JACKSON
9 Provider Business Practice Location Address State Name TN
10 Provider Business Practice Location Address Postal Code 383052800
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 7316682795
13 Provider Business Practice Location Address Fax Number 7316681012
14 Provider Enumeration Date 8/15/2012
15 Last Update Date 8/16/2012
16 Authorized Official Last Name CHRISTIE
17 Authorized Official First Name TODD
18 Authorized Official Title or Position CEO
19 Authorized Official Telephone Number 3218003771
20 Healthcare Provider Taxonomy Code 1 332BC3200X
21 Provider License Number 1 3105
22 Provider License Number State Code 1 TN
23 Healthcare Provider Primary Taxonomy Switch 1 Y
24 Is Organization Subpart Y
25 Parent Organization LBN DENTAL PRACTICE GROUP OF TENNESSEE
26 Parent Organization TIN
27 Authorized Official Name Prefix Text DR.
28 Authorized Official Credential Text DMD

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This page was last updated on: 9/11/2014
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