Provider Demographics
NPI:1558385872
Name:DIDDLE, JOHN A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:DIDDLE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 DUTCHTOWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-2745
Mailing Address - Country:US
Mailing Address - Phone:865-693-6561
Mailing Address - Fax:865-693-0522
Practice Address - Street 1:9220 DUTCHTOWN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4925
Practice Address - Country:US
Practice Address - Phone:865-693-6561
Practice Address - Fax:865-693-0522
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 27531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621063528OtherTAX ID