Provider Demographics
NPI:1356657852
Name:SCENIC CITY ORTHODONTICS PC
Entity Type:Organization
Organization Name:SCENIC CITY ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:423-855-4201
Mailing Address - Street 1:7003 SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-6722
Mailing Address - Country:US
Mailing Address - Phone:423-855-4201
Mailing Address - Fax:423-855-4203
Practice Address - Street 1:7003 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6722
Practice Address - Country:US
Practice Address - Phone:423-855-4201
Practice Address - Fax:423-855-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN90651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty