Provider Demographics
NPI:1881271161
Name:COLLEGEDALE FAMILY DENTISTRY P.C.
Entity type:Organization
Organization Name:COLLEGEDALE FAMILY DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-396-4222
Mailing Address - Street 1:9325 APISON PIKE STE 119
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-3802
Mailing Address - Country:US
Mailing Address - Phone:423-396-4222
Mailing Address - Fax:
Practice Address - Street 1:9325 APISON PIKE STE 119
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-3802
Practice Address - Country:US
Practice Address - Phone:423-396-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11462OtherDENTIST