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General NPI Number Information
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NPI Number | 1467758227
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Entity Type | Organization
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Legal Business Name | UNIVERSAL DENTAL ASSOC DSO LLC
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 08/01/2013
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Provider Practice Location Address
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Address Line | 712 W WALNUT ST
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6524
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Country | US
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Telephone | 423-928-5500
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Fax | 423-929-1505
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Provider Business Mailing Address
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Address Line | 712 W WALNUT ST
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6524
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Country | US
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Telephone | 423-928-5500
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Fax | 423-929-1505
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TONYA LYNN LANGENBRUNNER
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Credential |
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Telephone | 423-928-5500
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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 | DS3637
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License Number State | TN
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