Provider Demographics
NPI:1720125545
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:MCRO MOBILE DENTAL UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-650-7000
Mailing Address - Street 1:710 HART LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37216-2627
Mailing Address - Country:US
Mailing Address - Phone:615-650-7000
Mailing Address - Fax:615-262-6139
Practice Address - Street 1:710 HART LN
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37216-2627
Practice Address - Country:US
Practice Address - Phone:615-650-7000
Practice Address - Fax:615-262-6139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4447844Medicaid
TN014540OtherDORAL DENTAL LOCATION ID