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General NPI Number Information
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NPI Number | 1326685132
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Entity Type | Organization
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Legal Business Name | EAST NASHVILLE PEDIATRIC DENTISTRY, PLLC
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Dates
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Enumeration Date | 11/30/2019
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Last Update Date | 11/30/2019
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Provider Practice Location Address
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Address Line | 1077 E TRINITY LN STE 104
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City | NASHVILLE
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State | TN
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Zip | 37216-3067
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Country | US
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Telephone | 615-669-4858
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Fax | 615-669-4859
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Provider Business Mailing Address
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Address Line | 1809 MCEWEN AVE
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City | NASHVILLE
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State | TN
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Zip | 37206-1856
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Country | US
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Telephone | 615-669-4858
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Fax | 615-669-4859
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | MARISSA SANDIDGE
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Credential | DMD
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Telephone | 770-633-6566
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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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