Provider Demographics
NPI:1538456199
Name:SOUTHSIDE DENTAL ARTS, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE DENTAL ARTS, LLC
Other - Org Name:SMILE STUDIO ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORGANIZER/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:BALDREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-265-6685
Mailing Address - Street 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-1136
Mailing Address - Country:US
Mailing Address - Phone:423-265-6685
Mailing Address - Fax:423-265-8206
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-1136
Practice Address - Country:US
Practice Address - Phone:423-265-6685
Practice Address - Fax:423-265-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0050961223P0700X
TNDS0051631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty