Provider Demographics
NPI:1629364922
Name:CORDOVA DENTAL
Entity Type:Organization
Organization Name:CORDOVA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-759-0999
Mailing Address - Street 1:8333 CORDOVA RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2046
Mailing Address - Country:US
Mailing Address - Phone:901-759-0999
Mailing Address - Fax:901-758-8777
Practice Address - Street 1:8333 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2046
Practice Address - Country:US
Practice Address - Phone:901-759-0999
Practice Address - Fax:901-758-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty