Healthcare Provider Details

I. General information

NPI: 1548992480
Provider Name (Legal Business Name): OLIVIA HART GADDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7019 HIGHWAY 412 S
BELLS TN
38006-4140
US

IV. Provider business mailing address

398 JONES RD
BELLS TN
38006-3716
US

V. Phone/Fax

Practice location:
  • Phone: 731-663-9999
  • Fax:
Mailing address:
  • Phone: 731-345-9428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11958
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: