Provider Demographics
NPI:1578624458
Name:WIDNER, JOSEPH C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:C
Last Name:WIDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6058 HWY 412 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BELLS
Mailing Address - State:TN
Mailing Address - Zip Code:38006
Mailing Address - Country:US
Mailing Address - Phone:731-663-9999
Mailing Address - Fax:731-663-0510
Practice Address - Street 1:6058 HWY 412 SOUTH
Practice Address - Street 2:
Practice Address - City:BELLS
Practice Address - State:TN
Practice Address - Zip Code:38006
Practice Address - Country:US
Practice Address - Phone:731-663-9999
Practice Address - Fax:731-663-0510
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS36821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1502433Medicaid