MEDICARE: MOUNT JULIET FAMILY DENTISTRY

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
2	124Q00000X	Dental Hygienist
3	122300000X	Dentist	9932	TN

General Provider Information

NPI Number	:	1902338809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT JULIET FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	66 E HILL DR
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8031
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	66 E HILL DR
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8031
Country	:	US
Telephone Number	:	615-758-2085
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BAYAN FERDOWSI
Credential	:	DDS
Telephone Number	:	615-758-2085

Provider Enumeration Date	:	03/30/2017
Last Update Date	:	03/30/2017

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