Provider Demographics
NPI:1548423163
Name:KINGSTON DENTAL LLC
Entity Type:Organization
Organization Name:KINGSTON DENTAL LLC
Other - Org Name:MOBILE 33
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVON
Authorized Official - Middle Name:
Authorized Official - Last Name:HULSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-804-2465
Mailing Address - Street 1:820 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2635
Mailing Address - Country:US
Mailing Address - Phone:865-804-2465
Mailing Address - Fax:865-966-1229
Practice Address - Street 1:820 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2635
Practice Address - Country:US
Practice Address - Phone:865-804-2465
Practice Address - Fax:865-966-1229
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGSTON DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN18362OtherDORAL DENTAL OF TN