Provider Demographics
NPI:1437706041
Name:DENTISTS OF EAST BRAINERD, PC
Entity Type:Organization
Organization Name:DENTISTS OF EAST BRAINERD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-800-5991
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:8021 E BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3206
Practice Address - Country:US
Practice Address - Phone:423-800-5991
Practice Address - Fax:423-829-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty