Provider Demographics
NPI:1497142137
Name:KNOB CREEK ORAL CLINIC
Entity Type:Organization
Organization Name:KNOB CREEK ORAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDFORD
Authorized Official - Middle Name:W
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-467-5010
Mailing Address - Street 1:2306 KNOB CREEK RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2366
Mailing Address - Country:US
Mailing Address - Phone:423-467-5009
Mailing Address - Fax:
Practice Address - Street 1:2306 KNOB CREEK RD
Practice Address - Street 2:SUITE 108
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2366
Practice Address - Country:US
Practice Address - Phone:423-467-5009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000009647261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery