Provider Demographics
NPI:1477253268
Name:SOH OF TENNEESSEE SPECIALTY LLC
Entity Type:Organization
Organization Name:SOH OF TENNEESSEE SPECIALTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ASHLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-362-4986
Mailing Address - Street 1:1422 ELBRIDGE PAYNE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8544
Mailing Address - Country:US
Mailing Address - Phone:636-362-4986
Mailing Address - Fax:
Practice Address - Street 1:330 MAYFIELD DR STE A15
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-7210
Practice Address - Country:US
Practice Address - Phone:636-362-4986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty