=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720591084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SDM TENNESSEE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2017
-----------------------------------------------------
Last Update Date | 10/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 COMMERCE WAY STE 160
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-2875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-661-8818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 ROBINWOOD RD
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-6689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-233-3234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DAVID L BRYANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-233-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------