Provider Demographics
NPI:1730481540
Name:BRENTWOOD PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:BRENTWOOD PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CREGGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-377-3080
Mailing Address - Street 1:95 SEABOARD LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3031
Mailing Address - Country:US
Mailing Address - Phone:615-377-3080
Mailing Address - Fax:615-377-3088
Practice Address - Street 1:95 SEABOARD LN
Practice Address - Street 2:SUITE 102
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3031
Practice Address - Country:US
Practice Address - Phone:615-377-3080
Practice Address - Fax:615-377-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS8825261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509457Medicaid