Provider Demographics
NPI:1710442074
Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF CHATTANOOGA
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF CHATTANOOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:DYER
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-622-4173
Mailing Address - Street 1:4610 BRAINERD ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411
Mailing Address - Country:US
Mailing Address - Phone:423-622-4173
Mailing Address - Fax:423-629-9889
Practice Address - Street 1:4610 BRAINERD ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411
Practice Address - Country:US
Practice Address - Phone:423-622-4173
Practice Address - Fax:423-629-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty