=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548053887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREAM TEAM FAMILY DENTISTRY AND ORAL SURGERY LEBANON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2025
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 W BADDOUR PKWY STE B
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37087-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-200-6093
-----------------------------------------------------
Fax | 615-552-0080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1430 W BADDOUR PKWY STE B
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37087-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-200-6093
-----------------------------------------------------
Fax | 615-552-0080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. JAMIE DRISCOLL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-895-3232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------