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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