Provider Demographics
NPI:1871916668
Name:SMOKY MOUNTAIN PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:SMOKY MOUNTAIN PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:BODFORD
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-766-4884
Mailing Address - Street 1:550 TOWN CREEK RD E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6289
Mailing Address - Country:US
Mailing Address - Phone:865-766-4884
Mailing Address - Fax:
Practice Address - Street 1:550 TOWN CREEK RD E
Practice Address - Street 2:SUITE 101
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6289
Practice Address - Country:US
Practice Address - Phone:865-766-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9031261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522864Medicaid