Provider Demographics
NPI:1346588282
Name:CLARKSVILLE DENTAL CENTER- ST B
Entity Type:Organization
Organization Name:CLARKSVILLE DENTAL CENTER- ST B
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-645-9469
Mailing Address - Street 1:1715 WILMA RUDOLPH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6861
Mailing Address - Country:US
Mailing Address - Phone:931-645-2469
Mailing Address - Fax:931-551-9954
Practice Address - Street 1:1715 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6861
Practice Address - Country:US
Practice Address - Phone:931-645-2469
Practice Address - Fax:931-551-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8290122300000X
TN9114122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty