Provider Demographics
NPI:1174000780
Name:TENNESSEE DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS, PC
Other - Org Name:SECRET CITY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:351 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6756
Mailing Address - Country:US
Mailing Address - Phone:865-272-2806
Mailing Address - Fax:865-272-2767
Practice Address - Street 1:349 S ILLINOIS AVE STE 300
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6756
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-26
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty