Healthcare Provider Details

I. General information

NPI: 1104812213
Provider Name (Legal Business Name): MARTIN R PITTMAN DDS MS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W FAIRVIEW AVE
JOHNSON CITY TN
37604-5632
US

IV. Provider business mailing address

111 W FAIRVIEW AVE
JOHNSON CITY TN
37604-5632
US

V. Phone/Fax

Practice location:
  • Phone: 423-929-8011
  • Fax: 429-929-7811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD52049
License Number StateTN

VIII. Authorized Official

Name: MARTIN R PITTMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 423-929-8011