Provider Demographics
NPI:1528239589
Name:TOTAL DENTAL CENTER
Entity type:Organization
Organization Name:TOTAL DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNORA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:SINES
Authorized Official - Suffix:
Authorized Official - Credentials:BS, RN, MPH
Authorized Official - Phone:423-338-7777
Mailing Address - Street 1:108 LIFESTYLE WAY
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307-3914
Mailing Address - Country:US
Mailing Address - Phone:423-338-7777
Mailing Address - Fax:423-338-9326
Practice Address - Street 1:108 LIFESTYLE WAY
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307-3914
Practice Address - Country:US
Practice Address - Phone:423-338-7777
Practice Address - Fax:423-338-9326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN108283OtherDORAL TENNCARE