=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487764049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHODONTIC ASSOCIATES, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 SUNSET DR BLDG E # 5
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-2333
-----------------------------------------------------
Fax | 423-282-9337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 SUNSET DR BLDG E # 5
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-2333
-----------------------------------------------------
Fax | 423-282-9337
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MANAGER
-----------------------------------------------------
Name | DAVID J. STORIE
-----------------------------------------------------
Credential | D.M.D., M.S.
-----------------------------------------------------
Telephone | 423-282-2333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 6930
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------