Healthcare Provider Details

I. General information

NPI: 1235769241
Provider Name (Legal Business Name): FARRAGUT DENTAL STUDIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 W POINT DR STE 101
FARRAGUT TN
37934-2834
US

IV. Provider business mailing address

11201 W POINT DR STE 101
FARRAGUT TN
37934-2834
US

V. Phone/Fax

Practice location:
  • Phone: 865-288-0416
  • Fax: 865-288-7177
Mailing address:
  • Phone: 865-288-0416
  • Fax: 865-288-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAIRAV VYAS
Title or Position: OWNER
Credential: DDS
Phone: 865-288-0416