Provider Demographics
NPI:1508081233
Name:DRIVER, JERRY RAY (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:RAY
Last Name:DRIVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-0595
Mailing Address - Country:US
Mailing Address - Phone:931-268-9323
Mailing Address - Fax:
Practice Address - Street 1:103 EAST GORE AVE.
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-0595
Practice Address - Country:US
Practice Address - Phone:931-268-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000040171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0016452OtherTNCARE