Provider Demographics
NPI:1477796118
Name:COLUMBIA ORTHODONTICS, PC
Entity Type:Organization
Organization Name:COLUMBIA ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-490-3488
Mailing Address - Street 1:1324 TROTWOOD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4750
Mailing Address - Country:US
Mailing Address - Phone:931-490-3488
Mailing Address - Fax:931-381-4910
Practice Address - Street 1:1324 TROTWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4750
Practice Address - Country:US
Practice Address - Phone:931-490-3488
Practice Address - Fax:931-381-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS73611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty