Provider Demographics
NPI:1639333560
Name:NASHVILLE FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:NASHVILLE FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:DR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-845-1263
Mailing Address - Street 1:700 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-3948
Mailing Address - Country:US
Mailing Address - Phone:870-845-1263
Mailing Address - Fax:
Practice Address - Street 1:700 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3948
Practice Address - Country:US
Practice Address - Phone:870-845-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114553608Medicaid