Provider Demographics
NPI:1376999003
Name:BRENTWOOD PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BRENTWOOD PEDIATRIC DENTISTRY
Other - Org Name:NOLENSVILLE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CREGGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:615-377-3080
Mailing Address - Street 1:7146 NOLENSVILLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NOLENSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37135-9585
Mailing Address - Country:US
Mailing Address - Phone:615-377-3080
Mailing Address - Fax:615-283-3898
Practice Address - Street 1:7146 NOLENSVILLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NOLENSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37135-9585
Practice Address - Country:US
Practice Address - Phone:615-283-7397
Practice Address - Fax:615-283-3898
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENTWOOD PEDIATRIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88251223P0221X
TN92781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014908Medicaid
TN1509457Medicaid