Provider Demographics
NPI:1740589787
Name:RESTORATIVE DENTAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:RESTORATIVE DENTAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-648-0604
Mailing Address - Street 1:237 DUNBAR CAVE RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8852
Mailing Address - Country:US
Mailing Address - Phone:931-648-0604
Mailing Address - Fax:931-648-0605
Practice Address - Street 1:237 DUNBAR CAVE RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8852
Practice Address - Country:US
Practice Address - Phone:931-648-0604
Practice Address - Fax:931-648-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental