Healthcare Provider Details

I. General information

NPI: 1669459251
Provider Name (Legal Business Name): CUMBERLAND GAP ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WESTMORELAND ST
HARROGATE TN
37752-8202
US

IV. Provider business mailing address

PO BOX 15
HARROGATE TN
37752-0015
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-5719
  • Fax: 423-869-5749
Mailing address:
  • Phone: 423-869-5719
  • Fax: 423-869-5749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE BURTON DOUGLASS JR.
Title or Position: CEO AND PRESIDENT
Credential: DMD MSD
Phone: 423-869-5719