Provider Demographics
NPI:1831887553
Name:PEDIATRIC DENTAL PARTNERS
Entity type:Organization
Organization Name:PEDIATRIC DENTAL PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JOHNSON FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:865-229-4969
Mailing Address - Street 1:4153 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5214
Mailing Address - Country:US
Mailing Address - Phone:615-374-8951
Mailing Address - Fax:
Practice Address - Street 1:10238 HARDIN VALLEY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1609
Practice Address - Country:US
Practice Address - Phone:865-229-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty