=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174004170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRITY MOBILE DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 S CREST RD
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-5923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-535-5030
-----------------------------------------------------
Fax | 855-535-5030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 S CREST RD
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-5923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-535-5030
-----------------------------------------------------
Fax | 855-535-5030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENNIFER SUMMITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-535-5030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | DS8806
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------