Provider Demographics
NPI:1083338644
Name:MARYVILLE DENTAL CARE
Entity Type:Organization
Organization Name:MARYVILLE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-483-7851
Mailing Address - Street 1:400 LABORATORY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6808
Mailing Address - Country:US
Mailing Address - Phone:865-483-7851
Mailing Address - Fax:865-483-6391
Practice Address - Street 1:1401 MONTVALE STATION RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-5815
Practice Address - Country:US
Practice Address - Phone:865-984-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1881190619OtherNPI