Provider Demographics
NPI:1780831990
Name:STANSBURY, TRENT EVERETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:EVERETT
Last Name:STANSBURY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 OLD N KENTUCKY ST
Mailing Address - Street 2:KINGSTON DENTAL LLC
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2358
Mailing Address - Country:US
Mailing Address - Phone:865-717-3586
Mailing Address - Fax:865-717-3581
Practice Address - Street 1:1212 N KENTUCKY ST
Practice Address - Street 2:KINGSTON DENTAL LLC
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2328
Practice Address - Country:US
Practice Address - Phone:865-717-3586
Practice Address - Fax:865-717-3581
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8988122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515053Medicaid