=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841822301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURE ISLAND PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2020
-----------------------------------------------------
Last Update Date | 02/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 MEDICAL CENTER PARKWAY 110
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-444-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4119 SCOTT HOLLOW RD
-----------------------------------------------------
City | CULLEOKA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38451-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-444-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MISS LISA K PAUL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-698-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------