=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609653260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE DENTAL PROFESSIONALS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2023
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5261 AIRLINE RD STE 102
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-4267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-290-0885
-----------------------------------------------------
Fax | 901-290-0871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5261 AIRLINE RD STE 102
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-4267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-290-0885
-----------------------------------------------------
Fax | 901-290-0871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | BELINDA HUERTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------