MEDICARE: C. SUE VANBLARICUM, DDS, PC

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	1223G0001X	General Practice Dentistry	DS0000005005	TN

General Provider Information

NPI Number	:	1710091681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. SUE VANBLARICUM, DDS, PC

Provider Business Mailing Address
First Line	:	412 COLLEGE ST
Second Line	:
City	:	LAFAYETTE
State	:	TN
Zip	:	37083-1705
Country	:	US
Telephone Number	:	615-666-6155
Fax Number	:	615-666-7525

Provider Business Practice Location Address
First Line	:	412 COLLEGE ST
Second Line	:
City	:	LAFAYETTE
State	:	TN
Zip	:	37083-1705
Country	:	US
Telephone Number	:	615-666-6155
Fax Number	:	615-666-7525

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. C. SUE VANBLARICUM
Credential	:	DDS
Telephone Number	:	615-666-6155

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	08/22/2020

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