Healthcare Provider Details

I. General information

NPI: 1265837108
Provider Name (Legal Business Name): JERRIE J RAINES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 HIXSON PIKE STE C
HIXSON TN
37343-4466
US

IV. Provider business mailing address

4845 HIXSON PIKE STE C
HIXSON TN
37343-4466
US

V. Phone/Fax

Practice location:
  • Phone: 423-877-3848
  • Fax: 423-877-3726
Mailing address:
  • Phone: 423-877-3848
  • Fax: 423-877-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS3483
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: