Healthcare Provider Details

I. General information

NPI: 1477538809
Provider Name (Legal Business Name): PAUL H BACON JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MOUSE CREEK RD NW
CLEVELAND TN
37312-4840
US

IV. Provider business mailing address

33 MOUSE CREEK RD NW
CLEVELAND TN
37312-4840
US

V. Phone/Fax

Practice location:
  • Phone: 423-479-9395
  • Fax: 423-479-8372
Mailing address:
  • Phone: 423-479-9395
  • Fax: 423-479-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: