Provider Demographics
NPI:1720276009
Name:DEVALL, TERRY M (DMD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:M
Last Name:DEVALL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 JACKSON WALK PLZ
Mailing Address - Street 2:208
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 JACKSON WALK PLZ
Practice Address - Street 2:208
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3016
Practice Address - Country:US
Practice Address - Phone:901-604-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2285-861223G0001X
TN7852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2285-86OtherDENTAL LICENSE
TN7852OtherTENNESSEE DENTAL LICENSE NUMBER