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General NPI Number Information
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NPI Number | 1043730005
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Entity Type | Organization
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Legal Business Name | DICKENSON DENTAL
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Dates
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Enumeration Date | 06/21/2017
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Last Update Date | 06/21/2017
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Provider Practice Location Address
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Address Line | 2620 MINERAL SPRINGS AVE
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City | KNOXVILLE
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State | TN
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Zip | 37917-1569
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Country | US
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Telephone | 865-688-4442
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Fax |
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Provider Business Mailing Address
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Address Line | 10323 EVENING RIDGE LN
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City | KNOXVILLE
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State | TN
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Zip | 37922-7244
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. BRENT M DICKENSON
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Credential | DDS
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Telephone | 865-314-3859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 9681
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License Number State | TN
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