Provider Demographics
NPI:1013991686
Name:NORTHEAST TN PUBLIC HEALTH
Entity Type:Organization
Organization Name:NORTHEAST TN PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:B
Authorized Official - Last Name:VESTAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-979-3200
Mailing Address - Street 1:1233 SOUTHWEST AVE EXT
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-979-3200
Mailing Address - Fax:423-979-3267
Practice Address - Street 1:1233 SOUTHWEST AVE EXT
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-979-3200
Practice Address - Fax:423-979-3267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3209286Medicaid