Healthcare Provider Details

I. General information

NPI: 1487432811
Provider Name (Legal Business Name): LEGACY DENTAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 WILLIAMS RD
HIXSON TN
37343-4934
US

IV. Provider business mailing address

1605 WILLIAMS RD
HIXSON TN
37343-4934
US

V. Phone/Fax

Practice location:
  • Phone: 423-843-0418
  • Fax: 423-842-7362
Mailing address:
  • Phone: 423-843-0418
  • Fax: 423-842-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARCY KAY
Title or Position: INSURANCE ADMINISTRATOR
Credential:
Phone: 423-843-0418