Provider Demographics
NPI:1083860498
Name:KINGSTON DENTAL LLC
Entity Type:Organization
Organization Name:KINGSTON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVON
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HULSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-640-5283
Mailing Address - Street 1:1203 OLD N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2358
Mailing Address - Country:US
Mailing Address - Phone:865-717-3586
Mailing Address - Fax:865-717-3581
Practice Address - Street 1:1212 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2328
Practice Address - Country:US
Practice Address - Phone:865-717-3586
Practice Address - Fax:865-717-3581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515194Medicaid