Provider Demographics
NPI:1376976449
Name:ADULT AND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ADULT AND FAMILY DENTISTRY
Other - Org Name:ADULT ADN FAMILY DENTISTRY OF FOUNTAIN CITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-591-4829
Mailing Address - Street 1:5303 JACKSBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-3328
Mailing Address - Country:US
Mailing Address - Phone:865-687-8670
Mailing Address - Fax:
Practice Address - Street 1:5303 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-3328
Practice Address - Country:US
Practice Address - Phone:865-687-8670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty