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General NPI Number Information
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NPI Number | 1679879415
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Entity Type | Organization
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Legal Business Name | MAPLE LEAF IMPLANT AND GENERAL DENTISTRY, PLLC
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 02/15/2016
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Provider Practice Location Address
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Address Line | 220 N WASHINGTON AVE
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City | COOKEVILLE
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State | TN
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Zip | 38501-2642
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Country | US
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Telephone | 931-526-2613
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Fax | 931-646-0901
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Provider Business Mailing Address
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Address Line | 220 N WASHINGTON AVE
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City | COOKEVILLE
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State | TN
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Zip | 38501-2642
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Country | US
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Telephone | 931-526-2613
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Fax | 931-646-0901
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JERALD A BRYANT
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Credential | DDS
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Telephone | 931-526-2613
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7879
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License Number State | TN
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