Provider Demographics
NPI:1194045617
Name:CLARKSVILLE PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:CLARKSVILLE PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARYL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-245-3333
Mailing Address - Street 1:2297 RUDOLPHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-2226
Mailing Address - Country:US
Mailing Address - Phone:931-245-3333
Mailing Address - Fax:931-245-3334
Practice Address - Street 1:2297 RUDOLPHTOWN RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2226
Practice Address - Country:US
Practice Address - Phone:931-245-3333
Practice Address - Fax:931-245-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0160078OtherBLUE CROSS BLUE SHIELD OF TN
TN823192OtherUNITED CONCORDIA
TN112051OtherTENNCARE LOCATION NUMBER