Provider Demographics
NPI:1154087120
Name:SPARK DENTAL TN, PLLC
Entity Type:Organization
Organization Name:SPARK DENTAL TN, PLLC
Other - Org Name:CUMBERLAND PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-478-7166
Mailing Address - Street 1:1540 ROCK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6141
Mailing Address - Country:US
Mailing Address - Phone:615-930-3718
Mailing Address - Fax:615-625-3473
Practice Address - Street 1:1540 ROCK SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6141
Practice Address - Country:US
Practice Address - Phone:615-930-3718
Practice Address - Fax:615-625-3473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARK DENTAL TN, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-13
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ070323Medicaid