Provider Demographics
NPI:1033386313
Name:EAST BRAINERD FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:EAST BRAINERD FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MCDOWELL
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-892-8169
Mailing Address - Street 1:8190 E BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4301
Mailing Address - Country:US
Mailing Address - Phone:423-892-8169
Mailing Address - Fax:
Practice Address - Street 1:8190 E BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4301
Practice Address - Country:US
Practice Address - Phone:423-892-8169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN82621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6951150001OtherMEDICARE DMEPOS