# MAPLE LEAF IMPLANT AND GENERAL DENTISTRY, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679879415
- **Authorized official:** DR. JERALD A BRYANT DDS (DENTIST)
- **Authorized official phone:** (931) 526-2613

## Contact information

- **Practice address:** 220 N WASHINGTON AVE, COOKEVILLE, TN 38501-2642
- **Practice address phone:** (931) 526-2613
- **Practice address fax:** (931) 646-0901
- **Mailing address:** 220 N WASHINGTON AVE, COOKEVILLE, TN 38501-2642
- **Mailing address phone:** (931) 526-2613
- **Mailing address fax:** (931) 646-0901

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 7879 | TN | Yes |

## Other

- **Enumeration date:** 01/26/2011
- **Last updated:** 02/15/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | Q009025 | — | TN |