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General NPI Number Information
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NPI Number | 1174881965
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Entity Type | Organization
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Legal Business Name | CENTERVILLE DENTAL
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Dates
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Enumeration Date | 04/30/2012
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Last Update Date | 04/30/2012
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Provider Practice Location Address
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Address Line | 704 HIGHWAY 100 STE 101
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City | CENTERVILLE
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State | TN
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Zip | 37033-1171
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Country | US
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Telephone | 931-729-2664
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Fax | 931-729-2666
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Provider Business Mailing Address
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Address Line | 704 HIGHWAY 100 STE 101
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City | CENTERVILLE
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State | TN
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Zip | 37033-1171
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Country | US
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Telephone | 931-729-2664
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Fax | 931-729-2666
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAMIE M LEE
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Credential | DDS
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Telephone | 931-729-2664
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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 | 8074
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License Number State | TN
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