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General NPI Number Information
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NPI Number | 1386193068
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Entity Type | Organization
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Legal Business Name | RICHLAND CREEK DENTAL LLC
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Dates
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Enumeration Date | 09/23/2016
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Last Update Date | 09/23/2016
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Provider Practice Location Address
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Address Line | 1272 MARKET ST
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City | DAYTON
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State | TN
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Zip | 37321
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Country | US
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Telephone | 423-834-9900
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Fax |
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Provider Business Mailing Address
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Address Line | 668 DAYCO DR
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City | DAYTON
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State | TN
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Zip | 37321-6733
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. MCKENZIE BOLING
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Credential | DDS
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Telephone | 423-834-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10259
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License Number State | TN
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