Provider Demographics
NPI:1417033804
Name:ADVANCED DENTAL CONCEPTS PC
Entity Type:Organization
Organization Name:ADVANCED DENTAL CONCEPTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICO
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-584-7336
Mailing Address - Street 1:6311 KINGSTON PIKE
Mailing Address - Street 2:SUITE 8-W
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4906
Mailing Address - Country:US
Mailing Address - Phone:865-584-7336
Mailing Address - Fax:865-584-6208
Practice Address - Street 1:6311 KINGSTON PIKE
Practice Address - Street 2:SUITE 8-W
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4906
Practice Address - Country:US
Practice Address - Phone:865-584-7336
Practice Address - Fax:865-584-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS72701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525931Medicaid
TN110001OtherTN CARE LOCATION
TN1508041526OtherHYGENIST NPI #