Provider Demographics
NPI:1326685132
Name:EAST NASHVILLE PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:EAST NASHVILLE PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-633-6566
Mailing Address - Street 1:1809 MCEWEN AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-1856
Mailing Address - Country:US
Mailing Address - Phone:615-669-4858
Mailing Address - Fax:615-669-4859
Practice Address - Street 1:1077 E TRINITY LN STE 104
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37216-3067
Practice Address - Country:US
Practice Address - Phone:615-669-4858
Practice Address - Fax:615-669-4859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty