=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669614350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKMAN GROVE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2009
-----------------------------------------------------
Last Update Date | 03/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4183 FRANKLIN RD SUITE B5
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37128-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-907-4746
-----------------------------------------------------
Fax | 615-907-4796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4183 FRANKLIN RD SUITE B5
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37128-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-907-4746
-----------------------------------------------------
Fax | 615-907-4796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | BRENT STUART MILLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 615-907-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7855
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------