Provider Demographics
NPI:1568021285
Name:SOUTHEASTERN DENTAL OF MT JULIET PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN DENTAL OF MT JULIET PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-568-3258
Mailing Address - Street 1:631 S MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6319
Mailing Address - Country:US
Mailing Address - Phone:615-754-6677
Mailing Address - Fax:615-773-5002
Practice Address - Street 1:631 S MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6319
Practice Address - Country:US
Practice Address - Phone:615-754-6677
Practice Address - Fax:615-773-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164592226OtherDARREN FOSTER, DDS
1700203007OtherR. W. ARCHER
1932652302OtherKINJAL VORA, DDS