Provider Demographics
NPI:1568828143
Name:MD ABERNATHY JR DDS LLC
Entity Type:Organization
Organization Name:MD ABERNATHY JR DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOULTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:ABERNATHY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:731-847-6453
Mailing Address - Street 1:213 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-2018
Mailing Address - Country:US
Mailing Address - Phone:731-847-6453
Mailing Address - Fax:731-847-6399
Practice Address - Street 1:213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2018
Practice Address - Country:US
Practice Address - Phone:731-847-6453
Practice Address - Fax:731-847-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3005261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1502954Medicaid