Provider Demographics
NPI:1568854875
Name:TENNESSEE RIVER DENTAL, PLLC
Entity Type:Organization
Organization Name:TENNESSEE RIVER DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-877-3848
Mailing Address - Street 1:4845 HIXSON PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4466
Mailing Address - Country:US
Mailing Address - Phone:423-877-3848
Mailing Address - Fax:423-877-3726
Practice Address - Street 1:4845 HIXSON PIKE STE C
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4466
Practice Address - Country:US
Practice Address - Phone:423-877-3848
Practice Address - Fax:423-877-3726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9947261QD0000X
TN3483261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental