Provider Demographics
NPI:1891154373
Name:HENDERSONVILLE DENTAL SPA PLLC.
Entity Type:Organization
Organization Name:HENDERSONVILLE DENTAL SPA PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-991-5901
Mailing Address - Street 1:264 NEW SHACKLE ISLAND RD STE 105A
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2482
Mailing Address - Country:US
Mailing Address - Phone:615-991-5901
Mailing Address - Fax:
Practice Address - Street 1:264 NEW SHACKLE ISLAND RD STE 105A
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2482
Practice Address - Country:US
Practice Address - Phone:615-991-5901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN87371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty