Provider Demographics
NPI:1013190149
Name:CREATIVE SMILES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CREATIVE SMILES FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:731-665-7240
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:608 S. TRENTON ST
Mailing Address - City:RUTHERFORD
Mailing Address - State:TN
Mailing Address - Zip Code:38369-0038
Mailing Address - Country:US
Mailing Address - Phone:731-665-7240
Mailing Address - Fax:731-665-7268
Practice Address - Street 1:608 S TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:TN
Practice Address - Zip Code:38369-9715
Practice Address - Country:US
Practice Address - Phone:731-665-7240
Practice Address - Fax:731-665-7268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7612261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9181903OtherDORAL DENTAL
TN3130925OtherBLUE CROSS BLUE SHIELD
TN5440713Medicaid