Provider Demographics
NPI:1194147421
Name:JAMES T. DEBERRY, JR., DDS, MS, PC
Entity type:Organization
Organization Name:JAMES T. DEBERRY, JR., DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-691-1404
Mailing Address - Street 1:10261 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3276
Mailing Address - Country:US
Mailing Address - Phone:865-691-1404
Mailing Address - Fax:865-691-0836
Practice Address - Street 1:10261 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3276
Practice Address - Country:US
Practice Address - Phone:865-691-1404
Practice Address - Fax:865-691-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS20891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1225279359Medicaid