Healthcare Provider Details

I. General information

NPI: 1275707853
Provider Name (Legal Business Name): PROSPERITY COSMETIC & GENERAL DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 34TH AVE N SUITE A
NASHVILLE TN
37209-2502
US

IV. Provider business mailing address

908 34TH AVE N SUITE A
NASHVILLE TN
37209-2502
US

V. Phone/Fax

Practice location:
  • Phone: 615-720-3765
  • Fax: 615-327-0546
Mailing address:
  • Phone: 615-720-3765
  • Fax: 615-327-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number8455
License Number StateTN

VIII. Authorized Official

Name: DR. BRENDA LESIA MOORE II
Title or Position: DENTIST
Credential: DDS
Phone: 615-720-3765