Provider Demographics
NPI:1598755407
Name:BIVENS, DARRYL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:A
Last Name:BIVENS
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 1:5103 HIGHWAY 100
Mailing Address - Street 2:
Mailing Address - City:LYLES
Mailing Address - State:TN
Mailing Address - Zip Code:37098-1879
Mailing Address - Country:US
Mailing Address - Phone:931-670-5961
Mailing Address - Fax:888-552-9652
Practice Address - Street 1:5103 HIGHWAY 100
Practice Address - Street 2:
Practice Address - City:LYLES
Practice Address - State:TN
Practice Address - Zip Code:37098-1879
Practice Address - Country:US
Practice Address - Phone:931-670-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS68581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice