Provider Demographics
NPI:1104310895
Name:RENFROE FAMILY DENTAL
Entity type:Organization
Organization Name:RENFROE FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-232-7105
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-0538
Mailing Address - Country:US
Mailing Address - Phone:931-232-7105
Mailing Address - Fax:931-232-2242
Practice Address - Street 1:311 SPRING ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058-3227
Practice Address - Country:US
Practice Address - Phone:931-232-7105
Practice Address - Fax:931-232-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9114261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4274444OtherBLUE CROSS BLUE SHIELD OF TENNESSEE