Provider Demographics
NPI:1467739441
Name:CLARKSVILLE DENTAL SPA, PLLC
Entity Type:Organization
Organization Name:CLARKSVILLE DENTAL SPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-647-8437
Mailing Address - Street 1:800 WEATHERLY DR
Mailing Address - Street 2:STE. 103-B
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8957
Mailing Address - Country:US
Mailing Address - Phone:931-647-8437
Mailing Address - Fax:931-647-8439
Practice Address - Street 1:800 WEATHERLY DR
Practice Address - Street 2:STE. 103-B
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8957
Practice Address - Country:US
Practice Address - Phone:931-647-8437
Practice Address - Fax:931-647-8439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5442012Medicaid