Provider Demographics
NPI:1497040901
Name:THE DENTAL EDGE OF SMYRNA
Entity Type:Organization
Organization Name:THE DENTAL EDGE OF SMYRNA
Other - Org Name:CEDAR GROVE DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-220-6990
Mailing Address - Street 1:741 PRESIDENT PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6807
Mailing Address - Country:US
Mailing Address - Phone:615-220-6990
Mailing Address - Fax:615-220-6119
Practice Address - Street 1:741 PRESIDENT PL
Practice Address - Street 2:SUITE 120
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6807
Practice Address - Country:US
Practice Address - Phone:615-220-6990
Practice Address - Fax:615-220-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN78851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty