Provider Demographics
NPI:1275931958
Name:TENNESSEE DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS PC
Other - Org Name:WHITE HOUSE FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8330
Mailing Address - Street 1:301 WHITE HOUSE CROSSING WAY, STE. B
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 WHITE HOUSE CROSSING WAY, STE. B
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-1400
Practice Address - Country:US
Practice Address - Phone:855-233-0431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty