Provider Demographics
NPI:1134253305
Name:PARKS, ANITA JO (DDS)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:JO
Last Name:PARKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 RAILROAD ST STE D
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-2661
Mailing Address - Country:US
Mailing Address - Phone:731-658-6112
Mailing Address - Fax:731-658-6059
Practice Address - Street 1:390 RAILROAD ST STE D
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2661
Practice Address - Country:US
Practice Address - Phone:731-658-6112
Practice Address - Fax:731-658-6059
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN72631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4108150OtherBCBST
TN1764104OtherUNITED CONCORDIA
TN203022415OtherTAX ID
TN4108150OtherBCBST