Healthcare Provider Details

I. General information

NPI: 1427569664
Provider Name (Legal Business Name): SOUTHEAST MOBILE SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

842 BROOKSHIRE BLVD
MARYVILLE TN
37803-6475
US

IV. Provider business mailing address

842 BROOKSHIRE BLVD
MARYVILLE TN
37803-6475
US

V. Phone/Fax

Practice location:
  • Phone: 865-441-2527
  • Fax:
Mailing address:
  • Phone: 865-441-2527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDS9854
License Number StateTN

VIII. Authorized Official

Name: MRS. CALLIE MICHELE FISHEL
Title or Position: DENTAL HYGIENIST
Credential: RDH
Phone: 865-441-2527