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General NPI Number Information
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NPI Number | 1053616417
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Entity Type | Organization
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Legal Business Name | TINY TOWN DENTAL
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Dates
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Enumeration Date | 01/17/2011
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Last Update Date | 01/17/2011
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Provider Practice Location Address
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Address Line | 3402 CAINLO DR STE 100
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City | CLARKSVILLE
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State | TN
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Zip | 37042-0863
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Country | US
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Telephone | 931-920-0440
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Fax | 931-920-0434
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Provider Business Mailing Address
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Address Line | 3402 CAINLO DR STE 100
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City | CLARKSVILLE
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State | TN
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Zip | 37042-0863
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Country | US
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Telephone | 931-920-0440
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Fax | 931-920-0434
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | SHAWN FOSTER
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Credential |
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Telephone | 615-498-4323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8552
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License Number State | TN
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