=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679056683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYVILLE MODERN DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 06/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1053 HUNTERS XING
-----------------------------------------------------
City | ALCOA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37701-1850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-223-6705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 920050
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75392-0050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-845-8890
-----------------------------------------------------
Fax | 303-952-0892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DDS
-----------------------------------------------------
Name | DR. PHILIP BATES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 865-223-6705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------