Provider Demographics
NPI:1790905842
Name:SOUTHEASTERN DENTAL ASSOCIATES OF HIXSON
Entity Type:Organization
Organization Name:SOUTHEASTERN DENTAL ASSOCIATES OF HIXSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:VALADIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-870-0791
Mailing Address - Street 1:1963 NORTHPOINT BLVD.
Mailing Address - Street 2:SUITE 113
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-870-0791
Mailing Address - Fax:423-875-6951
Practice Address - Street 1:1963 NORTHPOINT BLVD.
Practice Address - Street 2:SUITE 113
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-870-0791
Practice Address - Fax:423-875-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty