1104310895 NPI number — RENFROE FAMILY DENTAL

Table of content: (NPI 1104310895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104310895 NPI number — RENFROE FAMILY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENFROE FAMILY DENTAL
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:
DEREK RENFROE, DMD
Provider Other Organization Name Type Code:
5
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:
1104310895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 538
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37058-0538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-232-7105
Provider Business Mailing Address Fax Number:
931-232-2242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37058-3227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-232-7105
Provider Business Practice Location Address Fax Number:
931-232-2242
Provider Enumeration Date:
06/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
931-232-7105

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  9114 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4274444 . This is a "BLUE CROSS BLUE SHIELD OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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