Provider Demographics
NPI:1740851492
Name:TRAILHEAD PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:TRAILHEAD PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHADBURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-218-0708
Mailing Address - Street 1:809 DUNBAR CT
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1496
Mailing Address - Country:US
Mailing Address - Phone:270-218-0708
Mailing Address - Fax:
Practice Address - Street 1:124 GOODVIEW WAY STE B
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3125
Practice Address - Country:US
Practice Address - Phone:270-218-0708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty