Healthcare Provider Details

I. General information

NPI: 1598755407
Provider Name (Legal Business Name): DARRYL A BIVENS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5103 HIGHWAY 100
LYLES TN
37098-1879
US

IV. Provider business mailing address

5103 HIGHWAY 100
LYLES TN
37098-1879
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-5961
  • Fax:
Mailing address:
  • Phone: 931-670-5961
  • Fax: 888-552-9652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS6858
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: