Healthcare Provider Details

I. General information

NPI: 1851756423
Provider Name (Legal Business Name): ROCKY TOP PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10261 KINGSTON PIKE
KNOXVILLE TN
37922-3276
US

IV. Provider business mailing address

10261 KINGSTON PIKE
KNOXVILLE TN
37922-3276
US

V. Phone/Fax

Practice location:
  • Phone: 865-691-1404
  • Fax: 865-691-0836
Mailing address:
  • Phone: 865-691-1404
  • Fax: 865-691-0836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9858
License Number StateTN

VIII. Authorized Official

Name: LEAYNNE SELLERS
Title or Position: OFFICE MANAGER
Credential:
Phone: 865-691-1404