Provider Demographics
NPI:1215243795
Name:ETOWAH DENTAL
Entity type:Organization
Organization Name:ETOWAH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:L
Authorized Official - Last Name:PATE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-333-5656
Mailing Address - Street 1:620 TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-1304
Mailing Address - Country:US
Mailing Address - Phone:423-623-7315
Mailing Address - Fax:423-626-5055
Practice Address - Street 1:620 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1304
Practice Address - Country:US
Practice Address - Phone:423-623-7315
Practice Address - Fax:423-626-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty