Provider Demographics
NPI:1861664898
Name:RIVERGATE DENTAL GROUP
Entity Type:Organization
Organization Name:RIVERGATE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-851-1777
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37070-0589
Mailing Address - Country:US
Mailing Address - Phone:615-851-1777
Mailing Address - Fax:615-851-0877
Practice Address - Street 1:919 CONFERENCE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1933
Practice Address - Country:US
Practice Address - Phone:615-851-1777
Practice Address - Fax:615-851-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS005013302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization