Provider Demographics
NPI:1457180838
Name:TAILWATER PRACTICE PARTNERS
Entity type:Organization
Organization Name:TAILWATER PRACTICE PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-303-3203
Mailing Address - Street 1:113 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3344
Mailing Address - Country:US
Mailing Address - Phone:731-587-4742
Mailing Address - Fax:
Practice Address - Street 1:113 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3344
Practice Address - Country:US
Practice Address - Phone:731-587-4742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAILWATER PRACTICE PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty