1679675052 NPI number — FAMILY & COSMETIC DENTISTRY OF SMYRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679675052 NPI number — FAMILY & COSMETIC DENTISTRY OF SMYRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY & COSMETIC DENTISTRY OF SMYRNA
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:
Provider Other Organization Name Type Code:
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:
1679675052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 NISSAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37167-4407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-355-1062
Provider Business Mailing Address Fax Number:
615-355-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 NISSAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37167-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-355-1062
Provider Business Practice Location Address Fax Number:
615-355-1933
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
615-355-1062

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)





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