=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164823035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDICE LESLIE COLEMAN DDS, MDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2014
-----------------------------------------------------
Last Update Date | 06/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3130 TOM AUSTIN HWY STE D
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37172-4519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-361-4116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3130 TOM AUSTIN HWY STE D
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37172-4519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-361-4116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 9815
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------