Organization
CUMBERLAND GAP ORTHODONTICS
Active
Organization
CUMBERLAND GAP ORTHODONTICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JESSE BURTON DOUGLASS JR. DMD MSD (CEO AND PRESIDENT)
(423) 869-5719
Entity
Organization
Contact information
Practice address
119 WESTMORELAND ST, HARROGATE, TN 37752-8202
(423) 869-5719
(423) 869-5749
Mailing address
PO BOX 15, HARROGATE, TN 37752-0015
(423) 869-5719
(423) 869-5749
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
013672
—
TN
05
—
60042058
—
KY
Enumeration date
12/27/2005
Last updated
03/17/2008
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