Healthcare Provider Details

I. General information

NPI: 1013991686
Provider Name (Legal Business Name): NORTHEAST TN PUBLIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 SOUTHWEST AVE EXT
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

1233 SOUTHWEST AVE EXT
JOHNSON CITY TN
37604
US

V. Phone/Fax

Practice location:
  • Phone: 423-979-3200
  • Fax: 423-979-3267
Mailing address:
  • Phone: 423-979-3200
  • Fax: 423-979-3267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. REBECCA B VESTAL
Title or Position: DENTAL DIRECTOR
Credential: DDS
Phone: 423-979-3200