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General NPI Number Information
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NPI Number | 1538679097
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Entity Type | Organization
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Legal Business Name | SANGO SMILES PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 10/10/2017
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Last Update Date | 10/10/2017
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Provider Practice Location Address
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Address Line | 2622 MADISON ST STE G
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City | CLARKSVILLE
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State | TN
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Zip | 37043-6555
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Country | US
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Telephone | 931-919-4898
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Fax | 931-919-4892
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Provider Business Mailing Address
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Address Line | 7520 LORDS CHAPEL DR
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City | NASHVILLE
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State | TN
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Zip | 37211-7040
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Country | US
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Telephone | 615-557-4442
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CRYSTAL RUCKER
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Credential | DMD
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Telephone | 615-557-4442
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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 | 8466
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License Number State | TN
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