Healthcare Provider Details

I. General information

NPI: 1326417635
Provider Name (Legal Business Name): HEART LEAF DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5247 OLD HARDING RD
FRANKLIN TN
37064-9409
US

IV. Provider business mailing address

12910 SHELBYVILLE RD STE 300
LOUISVILLE KY
40243-2404
US

V. Phone/Fax

Practice location:
  • Phone: 855-259-9183
  • Fax:
Mailing address:
  • Phone: 855-259-9183
  • Fax: 502-254-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS0000002831
License Number StateTN

VIII. Authorized Official

Name: RANDALL L RUDOLPH
Title or Position: OWNER
Credential: DDS
Phone: 855-259-9183