Provider Demographics
NPI:1699183327
Name:SOUTH GROVE DENTAL
Entity Type:Organization
Organization Name:SOUTH GROVE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:PO BOX 734753
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4753
Mailing Address - Country:US
Mailing Address - Phone:615-768-3251
Mailing Address - Fax:615-241-3009
Practice Address - Street 1:6690 NOLENSVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8803
Practice Address - Country:US
Practice Address - Phone:615-768-3251
Practice Address - Fax:615-241-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty