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General NPI Number Information
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NPI Number | 1336528207
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY DENTAL
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Dates
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Enumeration Date | 05/26/2015
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Last Update Date | 05/26/2015
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Provider Practice Location Address
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Address Line | 2805 OLD FORT PKWY SUITE A
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City | MURFREESBORO
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State | TN
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Zip | 37128-5115
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Country | US
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Telephone | 615-867-1735
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Fax | 615-895-9441
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Provider Business Mailing Address
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Address Line | 2805 OLD FORT PKWY SUITE A
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City | MURFREESBORO
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State | TN
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Zip | 37128-5115
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Country | US
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Telephone | 615-867-1735
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Fax | 615-895-9441
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. JAMIE A GRIDER
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Credential | DDS
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Telephone | 615-867-1735
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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 | 10050
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8431
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License Number State | TN
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