Healthcare Provider Details

I. General information

NPI: 1487082434
Provider Name (Legal Business Name): ABSOLUTE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1956 N JACKSON ST
TULLAHOMA TN
37388-2204
US

IV. Provider business mailing address

1956 N JACKSON ST
TULLAHOMA TN
37388-2204
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-8255
  • Fax: 931-563-5566
Mailing address:
  • Phone: 931-455-8255
  • Fax: 931-563-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH S DOCTORA
Title or Position: OWNER
Credential: DDS
Phone: 931-455-8255