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General NPI Number Information
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NPI Number | 1609235712
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Entity Type | Organization
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Legal Business Name | FOOTHILLS ENDODONTICS
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Dates
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Enumeration Date | 02/17/2016
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Last Update Date | 02/17/2016
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Provider Practice Location Address
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Address Line | 312 HIGH ST
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City | MARYVILLE
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State | TN
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Zip | 37804-5833
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Country | US
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Telephone | 865-982-8000
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Fax | 865-982-8512
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Provider Business Mailing Address
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Address Line | 312 HIGH STREET
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City | MARYVILLE
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State | TN
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Zip | 37804
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Country | US
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Telephone | 865-982-8000
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Fax | 865-982-8512
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SERENA M LOVEDAY
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Credential | O.M.
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Telephone | 865-982-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 5322
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License Number State | TN
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