Provider Demographics
NPI:1689056624
Name:JOHNSON CITY DENTAL
Entity Type:Organization
Organization Name:JOHNSON CITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NILAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-282-0042
Mailing Address - Street 1:1720 W. MARKET ST.
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6021
Mailing Address - Country:US
Mailing Address - Phone:423-282-0042
Mailing Address - Fax:
Practice Address - Street 1:1720 W. MARKET ST.
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6021
Practice Address - Country:US
Practice Address - Phone:423-282-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS92091223G0001X
TNDS40531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty