Healthcare Provider Details

I. General information

NPI: 1932838265
Provider Name (Legal Business Name): SUSAN JONES SHEPPARD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S CONCORD ST
KNOXVILLE TN
37919-3304
US

IV. Provider business mailing address

4641 COBBLESTONE CIR
KNOXVILLE TN
37938-3208
US

V. Phone/Fax

Practice location:
  • Phone: 865-637-5708
  • Fax:
Mailing address:
  • Phone: 865-591-5182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4575
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: