Provider Demographics
NPI:1710434204
Name:PEDIATRIC DENTISTRY OF LEBANON,PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF LEBANON,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-545-1812
Mailing Address - Street 1:103 PHYSICIANS WAY
Mailing Address - Street 2:STE 150
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-4132
Mailing Address - Country:US
Mailing Address - Phone:615-545-1812
Mailing Address - Fax:
Practice Address - Street 1:103 PHYSICIANS WAY
Practice Address - Street 2:STE 150
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4132
Practice Address - Country:US
Practice Address - Phone:615-545-1812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514855Medicaid