Healthcare Provider Details

I. General information

NPI: 1467152611
Provider Name (Legal Business Name): SOH OF TENNEESSEE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MAYFIELD DR STE A14
FRANKLIN TN
37067-7210
US

IV. Provider business mailing address

1422 ELBRIDGE PAYNE RD STE 240
CHESTERFIELD MO
63017-8544
US

V. Phone/Fax

Practice location:
  • Phone: 636-362-4986
  • Fax:
Mailing address:
  • Phone: 636-362-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ASHLY SUNSHINE
Title or Position: CREDENTIALING
Credential:
Phone: 636-362-4986