Provider Demographics
NPI:1659156719
Name:CRYSTAL CLEAR FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CRYSTAL CLEAR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKONNEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-584-3861
Mailing Address - Street 1:415 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-1818
Mailing Address - Country:US
Mailing Address - Phone:615-584-3861
Mailing Address - Fax:
Practice Address - Street 1:1210 HAZELWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3964
Practice Address - Country:US
Practice Address - Phone:615-930-2050
Practice Address - Fax:615-459-0568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1437897907Medicaid