Provider Demographics
NPI:1235427691
Name:BRENTWOOD DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:BRENTWOOD DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:OGLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-9889
Mailing Address - Street 1:1642 WESTGATE CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8194
Mailing Address - Country:US
Mailing Address - Phone:615-373-9889
Mailing Address - Fax:615-425-0320
Practice Address - Street 1:1642 WESTGATE CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8194
Practice Address - Country:US
Practice Address - Phone:615-373-9889
Practice Address - Fax:615-425-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80561223P0221X
TN80551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3206481Medicaid