Healthcare Provider Details

I. General information

NPI: 1861664898
Provider Name (Legal Business Name): RIVERGATE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 CONFERENCE DR SUITE 5
GOODLETTSVILLE TN
37072-1933
US

IV. Provider business mailing address

PO BOX 589
GOODLETTSVILLE TN
37070-0589
US

V. Phone/Fax

Practice location:
  • Phone: 615-851-1777
  • Fax: 615-851-1740
Mailing address:
  • Phone: 615-851-1777
  • Fax: 615-851-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberDS005013
License Number StateTN

VIII. Authorized Official

Name: DR. RODERICK VINCENT FRAZIER SR.
Title or Position: OWNER
Credential: DDS
Phone: 615-851-1777