=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487432811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY DENTAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 WILLIAMS RD
-----------------------------------------------------
City | HIXSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37343-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-843-0418
-----------------------------------------------------
Fax | 423-842-7362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 WILLIAMS RD
-----------------------------------------------------
City | HIXSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37343-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-843-0418
-----------------------------------------------------
Fax | 423-842-7362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE ADMINISTRATOR
-----------------------------------------------------
Name | MARCY KAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-843-0418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------