Provider Demographics
NPI:1851655187
Name:PEDIATRIC DENTISTRY OF CHATTANOOGA, PLLC
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CHATTANOOGA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MGR
Authorized Official - Prefix:
Authorized Official - First Name:SOMMER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-541-5427
Mailing Address - Street 1:P.O. BOX 4078
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-4078
Mailing Address - Country:US
Mailing Address - Phone:423-541-5500
Mailing Address - Fax:423-476-2680
Practice Address - Street 1:150 STUART CROSSING
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4065
Practice Address - Country:US
Practice Address - Phone:423-541-5500
Practice Address - Fax:423-476-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty