Healthcare Provider Details

I. General information

NPI: 1366614588
Provider Name (Legal Business Name): BLUE RIBBON DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 CHURCH ST
TIPTONVILLE TN
38079-1109
US

IV. Provider business mailing address

PO BOX 375
TIPTONVILLE TN
38079-0375
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-9091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number8178
License Number StateTN

VIII. Authorized Official

Name: DR. DENEAN RESHAY CARR
Title or Position: DENTIST
Credential:
Phone: 731-253-9091