Provider Demographics
NPI:1609211267
Name:EAST TENNESSEE PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:EAST TENNESSEE PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:865-859-0355
Mailing Address - Street 1:1103 CALLAHAN DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-1310
Mailing Address - Country:US
Mailing Address - Phone:865-859-0355
Mailing Address - Fax:865-859-0227
Practice Address - Street 1:1103 CALLAHAN DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912-1310
Practice Address - Country:US
Practice Address - Phone:865-859-0355
Practice Address - Fax:865-859-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty