Provider Demographics
NPI:1356676829
Name:BIG RIDGE FAMILY AND COSMETIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:BIG RIDGE FAMILY AND COSMETIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERSTRAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-877-1334
Mailing Address - Street 1:5606 HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3725
Mailing Address - Country:US
Mailing Address - Phone:423-877-1334
Mailing Address - Fax:
Practice Address - Street 1:5606 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3725
Practice Address - Country:US
Practice Address - Phone:423-877-1334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental