MEDICARE: DR. IRA LEE SIDWELL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS3767	TN

General Provider Information

NPI Number	:	1114907201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRA LEE SIDWELL DMD

Provider Business Mailing Address
First Line	:	1195 OLD HICKORY BLVD
Second Line	:	STE. 205
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4239
Country	:	US
Telephone Number	:	615-269-5223
Fax Number	:	615-269-6384

Provider Business Practice Location Address
First Line	:	1195 OLD HICKORY BLVD
Second Line	:	STE. 205
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4239
Country	:	US
Telephone Number	:	615-269-5223
Fax Number	:	615-269-6384

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	03/04/2014

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