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General NPI Number Information
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NPI Number | 1467345439
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Entity Type | Organization
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Legal Business Name | CENTER FOR ORAL RECONSTRUCTION
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Dates
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Enumeration Date | 05/30/2025
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Last Update Date | 05/30/2025
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Provider Practice Location Address
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Address Line | 2835 NORTHPOINT BLVD STE 105
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City | HIXSON
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State | TN
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Zip | 37343-4862
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Country | US
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Telephone | 423-223-5666
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Fax |
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Provider Business Mailing Address
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Address Line | 1373 BRIDGEVIEW DR
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City | CHATTANOOGA
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State | TN
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Zip | 37415-1468
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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
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Name | DR. MARCUS KENNETH RANDALL
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Credential | DMD
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Telephone | 423-223-5666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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