1023313533 NPI number — TENNESSEE DENTAL PROFESSIONALS PC

Table of content: (NPI 1023313533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023313533 NPI number — TENNESSEE DENTAL PROFESSIONALS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE DENTAL PROFESSIONALS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PADDOCK PLACE DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023313533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 OLD PLEASANT GROVE ROAD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MOUNT JULIET
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37122-3880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-758-4807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 OLD PLEASANT GROVE ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MOUNT JULIET
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37122-3880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-758-4807
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHICK
Authorized Official First Name:
KAM
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
217-540-5100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)