Healthcare Provider Details

I. General information

NPI: 1588030084
Provider Name (Legal Business Name): CHILDREN'S DENTAL HEALTH CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6509 HIGHWAY 41A SUITE B
PLEASANT VIEW TN
37146-7170
US

IV. Provider business mailing address

6509 HIGHWAY 41A SUITE B
PLEASANT VIEW TN
37146-7170
US

V. Phone/Fax

Practice location:
  • Phone: 615-256-7543
  • Fax: 615-256-8895
Mailing address:
  • Phone: 615-256-7543
  • Fax: 615-256-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9738
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9962
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9072
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9134
License Number StateTN

VIII. Authorized Official

Name: SABIN KANE EWING
Title or Position: OWNER
Credential: DDS
Phone: 615-256-7543