MEDICARE: MCEWEN DENTAL SPECIALITIES

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	7681	TN
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4747	TN
3	1223G0001X	General Practice Dentistry	6865	TN

General Provider Information

NPI Number	:	1538306329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCEWEN DENTAL SPECIALITIES

Provider Business Mailing Address
First Line	:	161 RAILROAD STREET SOUTH
Second Line	:
City	:	MCEWEN
State	:	TN
Zip	:	37101
Country	:	US
Telephone Number	:	931-582-6997
Fax Number	:	931-582-6989

Provider Business Practice Location Address
First Line	:	161 RAILROAD ST S
Second Line	:
City	:	MC EWEN
State	:	TN
Zip	:	37101-4762
Country	:	US
Telephone Number	:	931-582-6997
Fax Number	:	931-582-6989

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MRS. BRIDGETT N SPANGLER
Credential	:	RDA
Telephone Number	:	931-582-6997

Provider Enumeration Date	:	01/15/2009
Last Update Date	:	01/15/2009

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