Healthcare Provider Details

I. General information

NPI: 1780159368
Provider Name (Legal Business Name): TARA ERICSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6311 KINGSTON PIKE STE 27W
KNOXVILLE TN
37919-4900
US

IV. Provider business mailing address

6311 KINGSTON PIKE STE 27W
KNOXVILLE TN
37919-4900
US

V. Phone/Fax

Practice location:
  • Phone: 865-588-7862
  • Fax: 865-558-6849
Mailing address:
  • Phone: 865-588-7862
  • Fax: 865-558-6849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TAMMIE MOYERS
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 865-588-7862