Provider Demographics
NPI:1033386651
Name:COUNTY OF SULLIVAN
Entity Type:Organization
Organization Name:COUNTY OF SULLIVAN
Other - Org Name:KINGSPORT HEALTH CENTER DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-279-2777
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-0630
Mailing Address - Country:US
Mailing Address - Phone:423-279-2777
Mailing Address - Fax:423-279-2797
Practice Address - Street 1:1041 E SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5242
Practice Address - Country:US
Practice Address - Phone:423-224-1600
Practice Address - Fax:423-224-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare