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General NPI Number Information
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NPI Number | 1083338644
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Entity Type | Organization
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Legal Business Name | MARYVILLE DENTAL CARE
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Dates
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Enumeration Date | 09/28/2022
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Last Update Date | 09/28/2022
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Provider Practice Location Address
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Address Line | 1401 MONTVALE STATION RD
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City | MARYVILLE
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State | TN
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Zip | 37803-5815
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Country | US
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Telephone | 865-984-3800
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Fax |
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Provider Business Mailing Address
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Address Line | 400 LABORATORY RD STE 101
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City | OAK RIDGE
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State | TN
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Zip | 37830-6808
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Country | US
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Telephone | 865-483-7851
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Fax | 865-483-6391
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Authorized Official
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Title or Position | OFFICE
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Name | MRS. LAURA BULL
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Credential |
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Telephone | 865-483-7851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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