=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265572655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR P J WENK & DR P A WENK PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 LEINART ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37716-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-457-2860
-----------------------------------------------------
Fax | 865-457-5602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 LEINART ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37716-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-457-2860
-----------------------------------------------------
Fax | 865-457-5602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND DENTIST
-----------------------------------------------------
Name | DR. TIMOTHY ALLEN BIBLE
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 865-457-2860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS0000007253
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------