MEDICARE: L ALAN BACON DDS PC & JOHN COLLINS DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1154322451	OTHER	TN	MICHAEL L HAMLIN IND. NPI
2	1295736304	OTHER	TN	L ALAN BACON IND. NPI
3	1023019254	OTHER	TN	JOHN R COLLINS IND. NPI
4	1295736569	OTHER	TN	CARL W EILERS, JR IND NPI

General Provider Information

NPI Number	:	1972504389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L ALAN BACON DDS PC & JOHN COLLINS DDS PC

Provider Business Mailing Address
First Line	:	117 W SEVIER AVE
Second Line	:	SUITE 220
City	:	KINGSPORT
State	:	TN
Zip	:	37660-3799
Country	:	US
Telephone Number	:	423-224-3200
Fax Number	:	423-224-3208

Provider Business Practice Location Address
First Line	:	117 W SEVIER AVE
Second Line	:	SUITE 220
City	:	KINGSPORT
State	:	TN
Zip	:	37660-3799
Country	:	US
Telephone Number	:	423-224-3200
Fax Number	:	423-224-3208

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. DONNA L FULLER
Credential	:
Telephone Number	:	423-224-3200

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	03/01/2012

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1295736304 — DR. LARRY ALAN BACON DDS
Practice Location Address:

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37660-3799

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1922114529 — APPALACHIAN REHABILITATION PROFESSIONALS, PC
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Directions to “L ALAN BACON DDS PC & JOHN COLLINS DDS PC ” Practice Location

Language	Start Address	Practice Location

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