Provider Demographics
NPI:1588326144
Name:FAMILY DENTAL CENTER TRICITIES, PC
Entity type:Organization
Organization Name:FAMILY DENTAL CENTER TRICITIES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TATUM
Authorized Official - Middle Name:L
Authorized Official - Last Name:KINDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-247-6961
Mailing Address - Street 1:116 JACK WHITE DR STE 12
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2379
Mailing Address - Country:US
Mailing Address - Phone:423-247-6961
Mailing Address - Fax:423-247-5552
Practice Address - Street 1:116 JACK WHITE DR STE 12
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2379
Practice Address - Country:US
Practice Address - Phone:423-247-6961
Practice Address - Fax:423-247-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN8105OtherINSURANCE COMPANIES