Healthcare Provider Details

I. General information

NPI: 1386564136
Provider Name (Legal Business Name): EWING JACKSON THREET, II, DMD, MSD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 BLUE PEACOCK WAY STE 1
SEYMOUR TN
37865-3924
US

IV. Provider business mailing address

1364 DISTRICT LN APT 459
CHATTANOOGA TN
37406-1946
US

V. Phone/Fax

Practice location:
  • Phone: 865-280-2526
  • Fax:
Mailing address:
  • Phone: 704-390-6628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: EWING JACKSON THREET II
Title or Position: OWNER / ENDODONTIST
Credential: DMD
Phone: 704-390-6628