Provider Demographics
NPI:1982708020
Name:GEORGE M SHORT DDS MS PC
Entity Type:Organization
Organization Name:GEORGE M SHORT DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:731-668-3411
Mailing Address - Street 1:33 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2042
Mailing Address - Country:US
Mailing Address - Phone:731-668-3411
Mailing Address - Fax:731-668-3410
Practice Address - Street 1:33 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2042
Practice Address - Country:US
Practice Address - Phone:731-668-3411
Practice Address - Fax:731-668-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS24211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3219278Medicaid