Healthcare Provider Details

I. General information

NPI: 1891042461
Provider Name (Legal Business Name): ELIZABETH FELTS RANDALL D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH A FELTS D.M.D.

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 04/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 RIVERFRONT PKWY SUITE 102
CHATTANOOGA TN
37402-2185
US

IV. Provider business mailing address

951 RIVERFRONT PKWY SUITE 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 Number5960C1
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9462
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: