Provider Demographics
NPI:1629029657
Name:FOOTHILLS PEDIATRIC DENTRISTRY, P.C.
Entity Type:Organization
Organization Name:FOOTHILLS PEDIATRIC DENTRISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTISIT
Authorized Official - Prefix:
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:OSBORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-977-8700
Mailing Address - Street 1:121 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-6210
Mailing Address - Country:US
Mailing Address - Phone:865-977-8700
Mailing Address - Fax:865-977-5464
Practice Address - Street 1:121 PARLIAMENT DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-6210
Practice Address - Country:US
Practice Address - Phone:865-977-8700
Practice Address - Fax:865-977-5464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty