Healthcare Provider Details

I. General information

NPI: 1558366716
Provider Name (Legal Business Name): DWIGHT A DEBOW DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 N WILCOX DR
KINGSPORT TN
37660-4971
US

IV. Provider business mailing address

1203 N WILCOX DR
KINGSPORT TN
37660-4971
US

V. Phone/Fax

Practice location:
  • Phone: 423-247-5137
  • Fax:
Mailing address:
  • Phone: 423-247-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS 2129
License Number StateTN

VIII. Authorized Official

Name: DR. DWIGHT A DEBOW
Title or Position: DENTIST - ORTHODONTIST
Credential: DDS MS
Phone: 423-247-5137