Healthcare Provider Details

I. General information

NPI: 1194591875
Provider Name (Legal Business Name): SHINE PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 NASHVILLE PIKE STE 200
GALLATIN TN
37066-5259
US

IV. Provider business mailing address

116 CREIGHTON AVE
NASHVILLE TN
37206-2204
US

V. Phone/Fax

Practice location:
  • Phone: 314-306-0003
  • Fax:
Mailing address:
  • Phone: 314-306-0003
  • 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: DR. MICHAEL JOHN SEELIG
Title or Position: PRESIDENT
Credential: DMD, MS
Phone: 314-306-0003