Provider Demographics
NPI:1376902809
Name:FACIAL DENTAL CENTER, P.C.
Entity Type:Organization
Organization Name:FACIAL DENTAL CENTER, P.C.
Other - Org Name:JUST4TEENS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:V
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-827-2770
Mailing Address - Street 1:1720 GUNBARREL RD STE 310
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3192
Mailing Address - Country:US
Mailing Address - Phone:423-602-8642
Mailing Address - Fax:
Practice Address - Street 1:1720 GUNBARREL RD STE 310
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3192
Practice Address - Country:US
Practice Address - Phone:423-602-8642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS9121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017535Medicaid