=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376603977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLINT L SERR DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1916 E LAMAR ALEXANDER PKWY
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-5284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-983-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1916 E LAMAR ALEXANDER PKWY
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-5284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-983-4642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12086
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6606
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------