1790821148 NPI number — SOUTHEASTERN DENTAL ASSOCIATES OF SODDY DAISY

Table of content: (NPI 1790821148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790821148 NPI number — SOUTHEASTERN DENTAL ASSOCIATES OF SODDY DAISY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN DENTAL ASSOCIATES OF SODDY DAISY
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:
1790821148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 HARRISON LN
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SODDY DAISY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37379-4831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-332-0500
Provider Business Mailing Address Fax Number:
423-332-0920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 HARRISON LN
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SODDY DAISY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37379-4831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-332-0500
Provider Business Practice Location Address Fax Number:
423-332-0920
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-332-0500

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  8527 , 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)





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