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 Field Definition 1
1 NPI 1013265586 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name DENTAL PRACTICE GROUP OF TENNESSEE The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name JACKSON FAMILY DENTAL CARE Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 78 LYNOAK CV The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name JACKSON The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name TN The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 383052800 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 7316682795 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 7316681012 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 8/15/2012 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 8/16/2012 The date that a record was last updated or changed.
16 Authorized Official Last Name CHRISTIE The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
17 Authorized Official First Name TODD The first name of the authorized official.
18 Authorized Official Title or Position CEO The title or position of the authorized official.
19 Authorized Official Telephone Number 3218003771 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 332BC3200X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Provider License Number 1 3105 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
22 Provider License Number State Code 1 TN The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
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: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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