Healthcare Provider Details

I. General information

NPI: 1518969229
Provider Name (Legal Business Name): L ALAN BACON DDS PC & JOHN COLLINS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 PRINCETON RD SUITE 204
JOHNSON CITY TN
37601-2060
US

IV. Provider business mailing address

508 PRINCETON RD SUITE 204
JOHNSON CITY TN
37601-2060
US

V. Phone/Fax

Practice location:
  • Phone: 423-915-1072
  • Fax: 423-915-1075
Mailing address:
  • Phone: 423-915-1072
  • Fax: 423-915-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. DONNA L FULLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 423-224-3200