Healthcare Provider Details

I. General information

NPI: 1255235644
Provider Name (Legal Business Name): LEGACY DENTAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 CUMMINGS HWY STE 112
CHATTANOOGA TN
37419-2438
US

IV. Provider business mailing address

135 TWIN OAKS CT
DAYTON TN
37321-5979
US

V. Phone/Fax

Practice location:
  • Phone: 423-821-3279
  • Fax:
Mailing address:
  • Phone: 423-762-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MARCY KAY
Title or Position: INSURANCE ADMINISTRATOR
Credential:
Phone: 423-762-9992