Provider Demographics
NPI:1215679410
Name:ROGERSVILLE DENTAL CENTER
Entity type:Organization
Organization Name:ROGERSVILLE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-359-5815
Mailing Address - Street 1:1500 REYNOLDS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-8368
Mailing Address - Country:US
Mailing Address - Phone:063-595-8156
Mailing Address - Fax:
Practice Address - Street 1:110 S HASSON ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3616
Practice Address - Country:US
Practice Address - Phone:606-359-5815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental