Provider Demographics
NPI:1336528207
Name:LEGACY FAMILY DENTAL
Entity Type:Organization
Organization Name:LEGACY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-867-1735
Mailing Address - Street 1:2805 OLD FORT PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-5115
Mailing Address - Country:US
Mailing Address - Phone:615-867-1735
Mailing Address - Fax:615-895-9441
Practice Address - Street 1:2805 OLD FORT PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-5115
Practice Address - Country:US
Practice Address - Phone:615-867-1735
Practice Address - Fax:615-895-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8431122300000X
TN10050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty