Healthcare Provider Details

I. General information

NPI: 1447536776
Provider Name (Legal Business Name): ORTHODONTIC CARE OF TN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 MAYFIELD DR STE D
SMYRNA TN
37167-3035
US

IV. Provider business mailing address

98 MAYFIELD DR STE D
SMYRNA TN
37167-3035
US

V. Phone/Fax

Practice location:
  • Phone: 615-355-5822
  • Fax: 615-355-5899
Mailing address:
  • Phone: 615-355-5822
  • Fax: 615-355-5899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8951
License Number StateTN

VIII. Authorized Official

Name: MR. STEPHEN H CRAM
Title or Position: SECRETARY
Credential:
Phone: 615-355-5822