Healthcare Provider Details

I. General information

NPI: 1538306329
Provider Name (Legal Business Name): MCEWEN DENTAL SPECIALITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 RAILROAD ST S
MC EWEN TN
37101-4762
US

IV. Provider business mailing address

161 RAILROAD STREET SOUTH
MCEWEN TN
37101
US

V. Phone/Fax

Practice location:
  • Phone: 931-582-6997
  • Fax: 931-582-6989
Mailing address:
  • Phone: 931-582-6997
  • Fax: 931-582-6989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6865
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7681
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4747
License Number StateTN

VIII. Authorized Official

Name: MRS. BRIDGETT N SPANGLER
Title or Position: OFFICE ADMINISTRATOR
Credential: RDA
Phone: 931-582-6997