MEDICARE: DR. JOHN PICKARD PRIMM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS0000002902	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0004216	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1275597106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN PICKARD PRIMM DDS

Provider Business Mailing Address
First Line	:	PO BOX 176
Second Line	:
City	:	WHITE BLUFF
State	:	TN
Zip	:	37187-0176
Country	:	US
Telephone Number	:	615-797-2298
Fax Number	:	615-797-9958

Provider Business Practice Location Address
First Line	:	4527 HWY 70 EAST
Second Line	:
City	:	WHITE BLUFF
State	:	TN
Zip	:	37187
Country	:	US
Telephone Number	:	615-797-2298
Fax Number	:	615-797-9958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/08/2007

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