Provider Demographics
NPI:1710679071
Name:JUPITER 4GD, LLC
Entity Type:Organization
Organization Name:JUPITER 4GD, LLC
Other - Org Name:ADKISON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAYSON
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-453-8900
Mailing Address - Street 1:110 WINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3134
Mailing Address - Country:US
Mailing Address - Phone:615-453-8900
Mailing Address - Fax:
Practice Address - Street 1:110 WINWOOD DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3134
Practice Address - Country:US
Practice Address - Phone:615-453-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental