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General NPI Number Information
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NPI Number | 1861664898
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Entity Type | Organization
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Legal Business Name | RIVERGATE DENTAL GROUP
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Dates
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Enumeration Date | 03/31/2008
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Last Update Date | 03/31/2008
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Provider Practice Location Address
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Address Line | 919 CONFERENCE DR SUITE 5
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City | GOODLETTSVILLE
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State | TN
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Zip | 37072-1933
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Country | US
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Telephone | 615-851-1777
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Fax | 615-851-1740
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Provider Business Mailing Address
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Address Line | PO BOX 589
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City | GOODLETTSVILLE
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State | TN
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Zip | 37070-0589
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Country | US
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Telephone | 615-851-1777
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Fax | 615-851-0877
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Authorized Official
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Title or Position | OWNER
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Name | DR. RODERICK VINCENT FRAZIER SR.
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Credential | DDS
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Telephone | 615-851-1777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | DS005013
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License Number State | TN
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