Provider Demographics
NPI:1437557378
Name:PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY PC
Other - Org Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:865-558-8857
Mailing Address - Street 1:1516 COLEMAN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-3809
Mailing Address - Country:US
Mailing Address - Phone:865-558-8857
Mailing Address - Fax:865-558-0291
Practice Address - Street 1:1516 COLEMAN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-3809
Practice Address - Country:US
Practice Address - Phone:865-558-8857
Practice Address - Fax:865-558-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN99021223P0221X
TN37221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty