Provider Demographics
NPI:1538679097
Name:SANGO SMILES PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SANGO SMILES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-557-4442
Mailing Address - Street 1:7520 LORDS CHAPEL DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7040
Mailing Address - Country:US
Mailing Address - Phone:615-557-4442
Mailing Address - Fax:
Practice Address - Street 1:2622 MADISON ST STE G
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6555
Practice Address - Country:US
Practice Address - Phone:931-919-4898
Practice Address - Fax:931-919-4892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN84661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty