=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447668546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND DENTAL CARE OF TN, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 N MOUNT JULIET RD SUITE 300
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-4416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-773-0412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 N MOUNT JULIET RD SUITE 300
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-4416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-773-0412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRED SUPERVISOR
-----------------------------------------------------
Name | KIM WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-754-2295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------