Provider Demographics
NPI:1336459791
Name:RIVERGATE VILLAGE DENTAL
Entity Type:Organization
Organization Name:RIVERGATE VILLAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN/REGIONAL DIRECTOR OP
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-498-4323
Mailing Address - Street 1:1570 GALLATIN PIKE N
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2124
Mailing Address - Country:US
Mailing Address - Phone:615-865-6000
Mailing Address - Fax:615-865-6069
Practice Address - Street 1:1570 GALLATIN PIKE N
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2124
Practice Address - Country:US
Practice Address - Phone:615-865-6000
Practice Address - Fax:615-865-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty