Provider Demographics
NPI:1114199734
Name:DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NKUNGULA-HOWLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-832-6460
Mailing Address - Street 1:390 HARDING PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-3998
Mailing Address - Country:US
Mailing Address - Phone:615-832-6460
Mailing Address - Fax:615-832-6461
Practice Address - Street 1:390 HARDING PL
Practice Address - Street 2:SUITE 101
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-3998
Practice Address - Country:US
Practice Address - Phone:615-832-6460
Practice Address - Fax:615-832-6461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS75701223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226456Medicaid
TN3209516Medicaid