1972504389 NPI number — L ALAN BACON DDS PC & JOHN COLLINS DDS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972504389 NPI number — L ALAN BACON DDS PC & JOHN COLLINS DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L ALAN BACON DDS PC & JOHN COLLINS DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASSOCIATED ORAL AND MAXILLOFACIAL SURGEONS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972504389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 W SEVIER AVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-3200
Provider Business Mailing Address Fax Number:
423-224-3208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 W SEVIER AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3200
Provider Business Practice Location Address Fax Number:
423-224-3208
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
423-224-3200

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1154322451 . This is a "MICHAEL L HAMLIN IND. NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1295736304 . This is a "L ALAN BACON IND. NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1023019254 . This is a "JOHN R COLLINS IND. NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1295736569 . This is a "CARL W EILERS, JR IND NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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