Healthcare Provider Details

I. General information

NPI: 1174757702
Provider Name (Legal Business Name): FAIRVIEW DENTAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1696 FAIRVIEW BLVD STE 104
FAIRVIEW TN
37062-5144
US

IV. Provider business mailing address

PO BOX 306067
NASHVILLE TN
37230-6067
US

V. Phone/Fax

Practice location:
  • Phone: 615-799-9234
  • Fax: 615-799-9626
Mailing address:
  • Phone: 615-370-4605
  • Fax: 615-370-0778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS6982
License Number StateTN

VIII. Authorized Official

Name: DR. MICHAEL W EDGE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 615-799-9234