Provider Demographics
NPI:1073393336
Name:TAILWATER PRACTICE PARTNERS
Entity Type:Organization
Organization Name:TAILWATER PRACTICE PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOSTLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-479-2196
Mailing Address - Street 1:10 BURTON HILLS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-3004
Mailing Address - Country:US
Mailing Address - Phone:615-479-2196
Mailing Address - Fax:
Practice Address - Street 1:1701 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4601
Practice Address - Country:US
Practice Address - Phone:573-364-1599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TW NEW DENTISTRY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental