Provider Demographics
NPI:1821219023
Name:TENNESSEE DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS PC
Other - Org Name:BLACKMAN FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS COOD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2812 OLD FORT PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-4265
Mailing Address - Country:US
Mailing Address - Phone:615-896-9322
Mailing Address - Fax:615-896-2122
Practice Address - Street 1:2812 OLD FORT PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-4265
Practice Address - Country:US
Practice Address - Phone:615-896-9322
Practice Address - Fax:615-896-2122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-02
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty