1619141801 NPI number — ASSOCIATED CHILDREN'S DENTISTRY, PLLC

Table of content: (NPI 1619141801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619141801 NPI number — ASSOCIATED CHILDREN'S DENTISTRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATED CHILDREN'S DENTISTRY, PLLC
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:
6
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:
1619141801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 RIVERGATE PKWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37072-2033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-859-9994
Provider Business Mailing Address Fax Number:
615-859-9939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 RIVERGATE PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GOODLETTSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37072-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-859-9994
Provider Business Practice Location Address Fax Number:
615-859-9939
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
KEVIN
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
615-859-9994

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DS0000003715 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3225308 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DS0000003715 . This is a "TN STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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