Provider Demographics
NPI:1023313533
Name:TENNESSEE DENTAL PROFESSIONALS PC
Entity type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:20 OLD PLEASANT GROVE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3880
Mailing Address - Country:US
Mailing Address - Phone:615-758-4807
Mailing Address - Fax:
Practice Address - Street 1:20 OLD PLEASANT GROVE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3880
Practice Address - Country:US
Practice Address - Phone:615-758-4807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-13
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty