MEDICARE: SCENIC CITY ORTHODONTICS OF DALTON

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1932840048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCENIC CITY ORTHODONTICS OF DALTON

Provider Business Mailing Address
First Line	:	3326 JENKINS RD STE 101
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-1598
Country	:	US
Telephone Number	:	423-855-4201
Fax Number	:	423-855-4203

Provider Business Practice Location Address
First Line	:	1202 CLEO WAY STE 2
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-8428
Country	:	US
Telephone Number	:	423-855-4201
Fax Number	:	423-855-4203

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TYLER E PRENTICE
Credential	:	DMD
Telephone Number	:	423-855-4201

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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