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General NPI Number Information
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NPI Number | 1154087120
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Entity Type | Organization
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Legal Business Name | SPARK DENTAL TN, PLLC
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Dates
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Enumeration Date | 11/13/2021
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Last Update Date | 03/11/2022
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Provider Practice Location Address
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Address Line | 1540 ROCK SPRINGS RD
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City | SMYRNA
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State | TN
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Zip | 37167-6141
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Country | US
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Telephone | 615-930-3718
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Fax | 615-625-3473
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Provider Business Mailing Address
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Address Line | 1540 ROCK SPRINGS RD
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City | SMYRNA
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State | TN
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Zip | 37167-6141
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Country | US
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Telephone | 615-930-3718
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Fax | 615-625-3473
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Authorized Official
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Title or Position | REGIONAL MANAGER
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Name | CAROL LYNN GOINGS
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Credential |
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Telephone | 615-478-7166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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