Provider Demographics
NPI:1386209849
Name:SOUTHEASTERN DENTAL PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-568-3258
Mailing Address - Street 1:117 GALLATIN PIKE N
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-3701
Mailing Address - Country:US
Mailing Address - Phone:615-868-6177
Mailing Address - Fax:
Practice Address - Street 1:117 GALLATIN PIKE N
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-3701
Practice Address - Country:US
Practice Address - Phone:615-868-6177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental