Provider Demographics
NPI:1992194195
Name:SANDIDGE, MARISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:SANDIDGE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:LUDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1809 MCEWEN AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-1856
Mailing Address - Country:US
Mailing Address - Phone:770-633-6566
Mailing Address - Fax:
Practice Address - Street 1:1100 NEAL ST STE B
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0900
Practice Address - Country:US
Practice Address - Phone:931-240-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021436122300000X
TN103771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ026169Medicaid