Provider Demographics
NPI:1760614606
Name:RIVERGATE DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:RIVERGATE DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-370-4605
Mailing Address - Street 1:PO BOX 306087
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6087
Mailing Address - Country:US
Mailing Address - Phone:615-859-2262
Mailing Address - Fax:
Practice Address - Street 1:85 CUDE LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2292
Practice Address - Country:US
Practice Address - Phone:615-859-2262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS022261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty