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General NPI Number Information
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NPI Number | 1063493500
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Entity Type | Individual
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Provider Name | LEONARD RAY FUQUA JR. DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 11/10/2005
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Last Update Date | 07/05/2011
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Provider Practice Location Address
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Address Line | 505 N KENTUCKY ST
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City | KINGSTON
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State | TN
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Zip | 37763-2630
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Country | US
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Telephone | 865-376-4445
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Fax | 865-376-4441
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Provider Business Mailing Address
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Address Line | 505 N KENTUCKY ST
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City | KINGSTON
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State | TN
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Zip | 37763-2630
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Country | US
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Telephone | 865-376-4445
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Fax | 865-376-4441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DS0000002917
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License Number State | TN
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