Provider Demographics
NPI:1831173392
Name:J BENJAMIN RIVERS DMD PC
Entity type:Organization
Organization Name:J BENJAMIN RIVERS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:865-588-3850
Mailing Address - Street 1:6906 KINGSTON PIKE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5704
Mailing Address - Country:US
Mailing Address - Phone:865-588-3850
Mailing Address - Fax:865-588-3840
Practice Address - Street 1:6906 KINGSTON PIKE
Practice Address - Street 2:SUITE 205
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5704
Practice Address - Country:US
Practice Address - Phone:865-588-3850
Practice Address - Fax:865-588-3840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2075204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3215768Medicaid
T73888Medicare UPIN
TN3215768Medicare ID - Type Unspecified