Provider Demographics
NPI:1891178117
Name:NEELY, JOHN MINICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MINICK
Last Name:NEELY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3345
Mailing Address - Country:US
Mailing Address - Phone:615-444-3932
Mailing Address - Fax:
Practice Address - Street 1:1030 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3345
Practice Address - Country:US
Practice Address - Phone:615-444-3932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1510541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice