Provider Demographics
NPI:1730462458
Name:BLUE RIDGE FAMILY DENTISTRY DPC
Entity Type:Organization
Organization Name:BLUE RIDGE FAMILY DENTISTRY DPC
Other - Org Name:HARRISS FAMILY DENTISTRY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HARRISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-379-7004
Mailing Address - Street 1:824 W LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4578
Mailing Address - Country:US
Mailing Address - Phone:865-379-7004
Mailing Address - Fax:865-379-7040
Practice Address - Street 1:824 W LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4578
Practice Address - Country:US
Practice Address - Phone:865-379-7004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7985122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty