Provider Demographics
NPI:1700851979
Name:NOTHSIDE DENTAL CENTER, PA
Entity Type:Organization
Organization Name:NOTHSIDE DENTAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:731-668-7916
Mailing Address - Street 1:3067 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3411
Mailing Address - Country:US
Mailing Address - Phone:731-668-7916
Mailing Address - Fax:731-668-9544
Practice Address - Street 1:3067 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3411
Practice Address - Country:US
Practice Address - Phone:731-668-7916
Practice Address - Fax:731-668-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0149768OtherBLUE CROSS BLUE SHIELD TN