Healthcare Provider Details

I. General information

NPI: 1720692726
Provider Name (Legal Business Name): KODAK FAMILY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2020
Last Update Date: 09/07/2020
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 WINFIELD DUNN PKWY STE 301
KODAK TN
37764-4319
US

IV. Provider business mailing address

3428 WOODWARD DOWN TRL
BUFORD GA
30519-5054
US

V. Phone/Fax

Practice location:
  • Phone: 865-465-7058
  • Fax:
Mailing address:
  • Phone: 509-960-1744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NOELAN JURGEN SCHAFER
Title or Position: OWNER
Credential: DMD
Phone: 509-960-1744