Provider Demographics
NPI:1215426853
Name:EAST TENNESSEE PERIODONTICS, LLC
Entity type:Organization
Organization Name:EAST TENNESSEE PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-246-0460
Mailing Address - Street 1:2040 CASTAIC LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1557
Mailing Address - Country:US
Mailing Address - Phone:865-246-0460
Mailing Address - Fax:865-482-0592
Practice Address - Street 1:2040 CASTAIC LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1557
Practice Address - Country:US
Practice Address - Phone:865-246-0460
Practice Address - Fax:865-482-0592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty