Provider Demographics
NPI:1558988493
Name:AMMON, BLAINE
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:AMMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 KELSEY LN STE 1
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 KELSEY LN STE 1
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6480
Practice Address - Country:US
Practice Address - Phone:865-317-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11393122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty