Provider Demographics
NPI:1023572096
Name:TENNESSEE DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS, PC
Other - Org Name:MOUSE CREEK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:609 PAUL HUFF PKWY NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2970
Mailing Address - Country:US
Mailing Address - Phone:423-244-0783
Mailing Address - Fax:
Practice Address - Street 1:609 PAUL HUFF PKWY NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2970
Practice Address - Country:US
Practice Address - Phone:423-244-0783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-24
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty