Healthcare Provider Details

I. General information

NPI: 1619361441
Provider Name (Legal Business Name): PERIODONTAL & IMPLANT ASSOCIATES OF MIDDLET TENNESSEE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 OLD HICKORY BLVD SUITE 101
BRENTWOOD TN
37027-4241
US

IV. Provider business mailing address

1177 OLD HICKORY BLVD SUITE 101
BRENTWOOD TN
37027-4241
US

V. Phone/Fax

Practice location:
  • Phone: 615-988-2603
  • Fax: 615-988-2661
Mailing address:
  • Phone: 615-988-2603
  • Fax: 615-988-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN DAVID MEISTER
Title or Position: DOCTOR
Credential: DMD, MS
Phone: 615-988-2603