Provider Demographics
NPI:1881865509
Name:CREATIVE DENTISTRY P.C.
Entity Type:Organization
Organization Name:CREATIVE DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-321-0922
Mailing Address - Street 1:113 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1701
Mailing Address - Country:US
Mailing Address - Phone:615-321-0922
Mailing Address - Fax:615-329-9343
Practice Address - Street 1:113 23RD AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1701
Practice Address - Country:US
Practice Address - Phone:615-321-0922
Practice Address - Fax:615-329-9343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46701223G0001X
TN44641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225445Medicare PIN