Healthcare Provider Details

I. General information

NPI: 1063562460
Provider Name (Legal Business Name): CHATTANOOGA PERIODONTICS & DENTAL IMPLANTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 RIVERFRONT PKWY STE 102
CHATTANOOGA TN
37402-2185
US

IV. Provider business mailing address

951 RIVERFRONT PKWY STE 102
CHATTANOOGA TN
37402-2185
US

V. Phone/Fax

Practice location:
  • Phone: 423-756-2450
  • Fax: 423-756-5451
Mailing address:
  • Phone: 423-756-2450
  • Fax: 423-756-5451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS9462
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS3107
License Number StateTN

VIII. Authorized Official

Name: DR. CHARLES BAKER FELTS III
Title or Position: PRESIDENT
Credential: D.D.S., M.S.D
Phone: 423-756-2450