Provider Demographics
NPI:1851924369
Name:RENEW DENTAL
Entity Type:Organization
Organization Name:RENEW DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-799-7898
Mailing Address - Street 1:1835 MADISON ST STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6547
Mailing Address - Country:US
Mailing Address - Phone:931-291-9373
Mailing Address - Fax:
Practice Address - Street 1:1835 MADISON ST STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6547
Practice Address - Country:US
Practice Address - Phone:931-291-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942640750OtherOWNER-DENTIST
1760436729OtherASSOCIATE