=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558239905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDAR BLUFF DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2025
-----------------------------------------------------
Last Update Date | 10/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 MOSS GROVE BLVD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37922-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-690-2082
-----------------------------------------------------
Fax | 423-428-9270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 MAIN ST STE 400
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37321-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-690-2082
-----------------------------------------------------
Fax | 423-428-9270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MARCY KAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-762-9992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------