Healthcare Provider Details

I. General information

NPI: 1538158548
Provider Name (Legal Business Name): RICHARD D. FEWELL D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S JACKSON ST
TULLAHOMA TN
37388-4426
US

IV. Provider business mailing address

205 S JACKSON ST
TULLAHOMA TN
37388-4426
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-0146
  • Fax: 931-393-3863
Mailing address:
  • Phone: 931-455-0146
  • Fax: 931-393-3863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number261
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: