Provider Demographics
NPI:1619967676
Name:GOTCHER, JACK E JR (DMD,PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:GOTCHER
Suffix:JR
Gender:M
Credentials:DMD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440103
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0103
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6188
Practice Address - Street 1:1928 ALCOA HWY
Practice Address - Street 2:SUITE 305
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1502
Practice Address - Country:US
Practice Address - Phone:865-305-6625
Practice Address - Fax:865-305-6628
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000036541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3224964Medicaid
TN3224964Medicaid