Healthcare Provider Details

I. General information

NPI: 1023313533
Provider Name (Legal Business Name): TENNESSEE DENTAL PROFESSIONALS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 OLD PLEASANT GROVE ROAD SUITE 100
MOUNT JULIET TN
37122-3880
US

IV. Provider business mailing address

20 OLD PLEASANT GROVE ROAD SUITE 100
MOUNT JULIET TN
37122-3880
US

V. Phone/Fax

Practice location:
  • Phone: 615-758-4807
  • Fax:
Mailing address:
  • Phone: 615-758-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KAM SHICK
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 217-540-5100