Provider Demographics
NPI:1790189249
Name:DENTAL SPA PLLC
Entity Type:Organization
Organization Name:DENTAL SPA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BATTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-459-2579
Mailing Address - Street 1:PO BOX 2623
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-2623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 ENON SPRINGS RD E
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3032
Practice Address - Country:US
Practice Address - Phone:615-459-2579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12454814Medicaid