Healthcare Provider Details

I. General information

NPI: 1568952505
Provider Name (Legal Business Name): EAST TENNESSEE PEDIATRIC DENTISTRY AT OAK RIDGEPLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OAK RIDGE TPKE
OAK RIDGE TN
37830-7109
US

IV. Provider business mailing address

500 OAK RIDGE TPKE
OAK RIDGE TN
37830-7109
US

V. Phone/Fax

Practice location:
  • Phone: 865-859-0357
  • Fax: 865-859-0247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9446
License Number StateTN

VIII. Authorized Official

Name: DR. JESSICA PHILLIPS
Title or Position: OWNER
Credential: DMD
Phone: 865-859-0355