Provider Demographics
NPI:1568932341
Name:TENNESSEE DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS, PC
Other - Org Name:DENTAL CARE OF LEE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1730 LEE VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6674
Mailing Address - Country:US
Mailing Address - Phone:615-751-5087
Mailing Address - Fax:
Practice Address - Street 1:1730 LEE VICTORY PKWY
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6674
Practice Address - Country:US
Practice Address - Phone:615-355-0269
Practice Address - Fax:615-462-7490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-05
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty