Healthcare Provider Details

I. General information

NPI: 1649576190
Provider Name (Legal Business Name): LAKEWAY DENTAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 HIGHWAY 11W
BEAN STATION TN
37708-5810
US

IV. Provider business mailing address

1277 HIGHWAY 11W
BEAN STATION TN
37708-5810
US

V. Phone/Fax

Practice location:
  • Phone: 865-993-2225
  • Fax: 865-993-2225
Mailing address:
  • Phone: 865-993-2225
  • Fax: 865-993-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS9208
License Number StateTN

VIII. Authorized Official

Name: DR. DANA M JOHNSON
Title or Position: DENTIST
Credential: DMD
Phone: 865-993-2225