Provider Demographics
NPI:1043617657
Name:PREMIER FAMILY DENTAL
Entity Type:Organization
Organization Name:PREMIER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-505-3750
Mailing Address - Street 1:1963 NORTHPOINT BLVD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1963 NORTHPOINT BLVD
Practice Address - Street 2:SUITE 113
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4631
Practice Address - Country:US
Practice Address - Phone:423-551-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9373261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental