Healthcare Provider Details

I. General information

NPI: 1356432041
Provider Name (Legal Business Name): KINGSTON FAMILY PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W RACE ST
KINGSTON TN
37763-2120
US

IV. Provider business mailing address

820 W RACE ST
KINGSTON TN
37763-2120
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-3406
  • Fax: 865-376-9091
Mailing address:
  • Phone: 865-376-3406
  • Fax: 865-376-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DWIGHT H WILLETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 865-376-3406