Provider Demographics
NPI:1134391154
Name:DONALD S. REDFORD, D.D.S, P.C
Entity type:Organization
Organization Name:DONALD S. REDFORD, D.D.S, P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:REDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-968-4114
Mailing Address - Street 1:350 BLOUNTVILLE HWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-0213
Mailing Address - Country:US
Mailing Address - Phone:423-968-4114
Mailing Address - Fax:424-968-4294
Practice Address - Street 1:350 BLOUNTVILLE HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-0213
Practice Address - Country:US
Practice Address - Phone:423-968-4114
Practice Address - Fax:424-968-4294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2013-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0038451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0020203Medicaid
VA008019894Medicaid
TNT74383Medicare UPIN