Provider Demographics
NPI:1467758227
Name:UNIVERSAL DENTAL ASSOC DSO LLC
Entity Type:Organization
Organization Name:UNIVERSAL DENTAL ASSOC DSO LLC
Other - Org Name:UNIVERSITY DENTAL ASSOC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LANGENBRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-928-5500
Mailing Address - Street 1:712 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6524
Mailing Address - Country:US
Mailing Address - Phone:423-928-5500
Mailing Address - Fax:423-929-1505
Practice Address - Street 1:712 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6524
Practice Address - Country:US
Practice Address - Phone:423-928-5500
Practice Address - Fax:423-929-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225187Medicaid
TN12211029OtherCAQH