Provider Demographics
NPI:1831296425
Name:TATUM, MITCHELL SCOTT (DDS,)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:SCOTT
Last Name:TATUM
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 1:201 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37166-1712
Mailing Address - Country:US
Mailing Address - Phone:615-597-4798
Mailing Address - Fax:615-597-3171
Practice Address - Street 1:201 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-1712
Practice Address - Country:US
Practice Address - Phone:615-597-4798
Practice Address - Fax:615-597-3171
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 7129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3142596OtherBLUE CROSS BLUE SHIELD