Provider Demographics
NPI:1215922356
Name:PRINCE, TIDENCE LANE (MD)
Entity type:Individual
Prefix:DR
First Name:TIDENCE
Middle Name:LANE
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 W. LAMAR ALEXANDER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-7360
Mailing Address - Country:US
Mailing Address - Phone:865-273-0008
Mailing Address - Fax:
Practice Address - Street 1:616 W. LAMAR ALEXANDER PARKWAY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4763
Practice Address - Country:US
Practice Address - Phone:865-273-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21247207K00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3068515Medicaid