=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346999513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAVO WEBB PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2022
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3687 RHEA COUNTY HWY
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37321-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-870-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4803 HIXSON PIKE STE 101
-----------------------------------------------------
City | HIXSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37343-4486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-870-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL COORDINATOR
-----------------------------------------------------
Name | RACHEL SHERLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-870-5254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------