Provider Demographics
NPI:1275707853
Name:PROSPERITY COSMETIC & GENERAL DENTISTRY
Entity Type:Organization
Organization Name:PROSPERITY COSMETIC & GENERAL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LESIA
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-720-3765
Mailing Address - Street 1:908 34TH AVE N
Mailing Address - Street 2:SUITE A
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-2502
Mailing Address - Country:US
Mailing Address - Phone:615-720-3765
Mailing Address - Fax:615-327-0546
Practice Address - Street 1:908 34TH AVE N
Practice Address - Street 2:SUITE A
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-2502
Practice Address - Country:US
Practice Address - Phone:615-720-3765
Practice Address - Fax:615-327-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8455302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440336Medicaid