Healthcare Provider Details

I. General information

NPI: 1437557378
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 COLEMAN RD SUITE 201
KNOXVILLE TN
37909-3809
US

IV. Provider business mailing address

1516 COLEMAN RD SUITE 201
KNOXVILLE TN
37909-3809
US

V. Phone/Fax

Practice location:
  • Phone: 865-558-8857
  • Fax: 865-558-0291
Mailing address:
  • Phone: 865-558-8857
  • Fax: 865-558-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3722
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9902
License Number StateTN

VIII. Authorized Official

Name: DR. MICHAEL JAMES KOCH
Title or Position: BUSINESS MANAGER
Credential: DC
Phone: 865-558-8857