Basic Information
| Provider Information | |||||||||
| NPI: | 1285899666 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EARL DWAYNE LETT, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LETT CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 W BADDOUR PKWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370872513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154430901 | ||||||||
| FaxNumber: | 6154430310 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 W BADDOUR PKWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370872513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154430901 | ||||||||
| FaxNumber: | 6154430310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | LETT | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | DWAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/M.D. | ||||||||
| AuthorizedOfficialTelephone: | 6154430901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 25738 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3803222 | 05 | TN | MEDICAID |