Provider Demographics
NPI:1285899666
Name:EARL DWAYNE LETT, PC
Entity type:Organization
Organization Name:EARL DWAYNE LETT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:LETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-443-0901
Mailing Address - Street 1:1417 W BADDOUR PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-443-0901
Mailing Address - Fax:615-443-0310
Practice Address - Street 1:1417 W BADDOUR PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-443-0901
Practice Address - Fax:615-443-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25738208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3803222Medicaid
E74340Medicare UPIN
3803225Medicare PIN