=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225695380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORRISTOWN ENDODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2019
-----------------------------------------------------
Last Update Date | 08/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2729 W ANDREW JOHNSON HWY
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-621-2000
-----------------------------------------------------
Fax | 423-621-2001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 532
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-621-2000
-----------------------------------------------------
Fax | 423-621-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / ENDODONTIST
-----------------------------------------------------
Name | STRUDWICK LOUIS TUTWILER
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 423-621-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------