Organization
UNIVERSAL DENTAL ASSOC DSO LLC
Active
Other names
university dental assoc
Organization subpart
No
Provider details
NPI number
Authorized official
TONYA LYNN LANGENBRUNNER (OFFICE MANAGER)
(423) 928-5500
Entity
Organization
Contact information
Practice address
712 W WALNUT ST, JOHNSON CITY, TN 37604-6524
(423) 928-5500
(423) 929-1505
Mailing address
712 W WALNUT ST, JOHNSON CITY, TN 37604-6524
(423) 928-5500
(423) 929-1505
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DS3637
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12211029
CAQH
TN
05
—
3225187
—
TN
Enumeration date
01/26/2011
Last updated
08/01/2013
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