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General NPI Number Information
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NPI Number | 1740851492
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Entity Type | Organization
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Legal Business Name | TRAILHEAD PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 07/04/2021
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Last Update Date | 10/04/2023
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Provider Practice Location Address
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Address Line | 124 GOODVIEW WAY STE B
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City | GALLATIN
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State | TN
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Zip | 37066-3125
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Country | US
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Telephone | 270-218-0708
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Fax |
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Provider Business Mailing Address
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Address Line | 809 DUNBAR CT
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City | GOODLETTSVILLE
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State | TN
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Zip | 37072-1496
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Country | US
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Telephone | 270-218-0708
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. JONATHAN DAVID SHADBURNE
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Credential | DMD
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Telephone | 270-218-0708
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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 |
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License Number State |
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